Every finding on record at Evergreen Post Acute

Based on record review and interview, it was determined that for one (R155) out of one resident reviewed for hydration, the facility failed to ensure that R155 was offered sufficient fluids to maintain proper hydration. This failure resulted in harm with R155 being transferred to the hospital on [DATE] with diagnoses of dehydration and AKI (acute kidney injury). Findings include:The BUN (blood urea nitrogen) lab measures the amount of urea nitrogen in the blood. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidney . BUN levels also may vary according to the state of hydration, with increased levels seen in dehydration and decreased levels seen in overhydration. Mosby's Diagnostic and Laboratory Test Reference 2023. Review of R155's clinical record revealed:6/12/25 - R155 was admitted to the facility. 6/17/25 - A care plan documented that R155 was at risk for nutrition/hydration risk related to dementia, hypokalemia, hyponatremia, aphasia, hemiparesis, hemiplegia, and cerebral vascular accident (CVA) with the following interventions: honor food and beverage preferences as able; provide and serve diet, snacks and fluids as ordered; provide assistance with meal tray set up and/or feeding assistance; provide nutrient-relevant medications and supplements as ordered; and Registered Dietician (RD) to make dietary recommendations as needed. 6/17/25 11:12 AM - A nutrition assessment documented the recommended fluid intake for R155 was 2050 mL/day. The nutrition assessment further identified R155 was at risk for malnutrition and dehydration related to diagnoses of dementia, hemiplegia, and hemiparesis. The assessment additionally referenced laboratory results obtained on 6/16/25 which documented the following values: Sodium 148 (high) and Potassium 3.1 (low). The assessment further documented the provider ordered additional oral fluids for two weeks related to the electrolyte imbalance. 9/18/25 - A quarterly MDS documented that R115 had a BIMs score of 3 indicating severe cognitive impairment and required supervision or touching assistance for eating/drinking. 9/18/25 1:35 PM - A quarterly nutritional assessment documented that R155 had maintained stable weight since admission, had good oral food and fluid intake and remains on mechanical soft diet with no chewing or swallowing difficulty. No other nutrition concerns at this time and continue to monitor R155's nutritional status. The daily totals obtained from CNA task flow sheet for R155's fluid intake:10/1/25 - 1360 mL.10/2/25 - 720 mL.10/3/25 - 960 mL.10/4/25 - 1360 mL.10/5/25 - 1360 mL.10/6/25 - 960 mL.10/7/25 - 840 mL.10/8/25 - 480 mL.10/9/25 - 2000 mL.10/10/25 - 480 mL.10/11/25 - 1200 mL.10/12/25 - 920 mL.10/13/25 - 240 mL.10/14/25 - 1120 mL.10/15/25 - 1440 mL.10/16/25 - 720 mL.10/17/25 - 240 mL.10/18/25 - 960 mL.10/19/25 - 1680 mL.10/20/25 - 480 mL.10/20/25 1:00 AM - A provider's progress note documented that R155 was seen due to nursing reported R155 was noted with increased fatigue and slow to respond. The provider plan documented to check CBC, CMP, Vit D and B12 lab levels and encourage fluids. Despite provider recommending encouraging fluids, the facility failed to implement provider recommendation and lacked the evidence of increased monitoring and implementing approaches to increase hydration. The daily totals obtained from CNA task flow sheet for R155's fluid intake:10/21/25 - 0 mL.10/21/25 10:39 AM - A laboratory results report documented that R155 had the following lab values: BUN level 42 mg/dL, creatinine 1.50 mg/dL, and sodium 159 mmol/L. 10/21/25 2:22 PM - A progress note documented that labs were reviewed by provider and indicative of hypernatremia and AKI, fluid resuscitation was unsuccessful and initiated a new order to send R155 to the hospital.10/21/25 2:44 PM - A progress note documented that R155 was sent to the hospital via ambulance. 10/21/25 4:49 PM - A hospital progress note documented that R155 had lab values of BUN of 40 mg/dL and creatinine 1.5 mg/dL upon arrival to emergency department. The progress note further documented that R155 was being admitted with diagnosis of AKI, hypernatremia, hypokalemia and dehydration. The progress note documented the plan to correct was IV fluid resuscitation during admission. 10/21/25 1:00 AM - A provider progress note documented that R155 was seen for increased fatigue, lab review, and slow to respond. The progress note documented that R155's lab values were as follows: BUN 42 mg/dL, creatinine 1.50 mg/dL and Sodium 159 mmol/L. The provider recommended IV (intravenous) fluid resuscitation and to send R155 to hospital if unable to establish an IV line. 5/11/26 1:02 PM - During an interview, E14 (CNA) stated the expectation is for staff to record any fluids provided during meals and hydration rounds in the electronic system. E14 stated that staff was to report any changes noted in intake by residents to the nurse when observed. 5/11/26 1:07 PM - During an interview, E15 (CNA) stated the expectation is for staff to record all fluid intake and report any changes to the nurse.5/11/26 1:10 PM - During an interview, E16 (LPN) stated that R155 required assistance from staff with eating and drinking and had a good appetite. E16 further stated that nurses were expected to monitor resident's intake and report any changes to the Unit Manager or dietician. 5/11/26 1:15 PM - During an interview, E17 (RN) stated that resident's not meeting fluid volume goals are to be reported to the Unit Manager who will notify the provider and/or dietician to evaluate resident. E17 stated that she was unable to recall who attempted to initiate the IV line on R155 and stated the orders were not placed in the system due to unsuccessful insertion of the IV. E17 stated typically the orders would be added to EMR after the IV line was established. 5/11/26 3:20 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on interview, record review and review of other facility documentation, it was determined that for one (R109) out of seven residents reviewed for accidents, the facility failed to provide adequate supervision and implement safe bed mobility practices to prevent a fall. As a result, R109 fell from the bed, sustained a head laceration, required hospital transfer, and received six sutures causing harm to the resident. Findings include:Review of R109 clinical record revealed:6/9/25 - R109 was admitted to the facility with diagnoses including seizures, gastrostomy tube, tracheostomy, anxiety, and muscle spasms.A care plan last updated 6/10/25 documented ADL self-care deficit related to physical limitations. Interventions included assistance with daily hygiene, grooming, dressing, oral care, and eating as needed. The care plan further documented R109 required a two-person assist for transfers and bed mobility. Additionally, the care plan documented R109 was at risk for falls related to poor safety awareness, seizure and adjustment to a new environment. Interventions included assessing for fall risk on admission, quarterly, and as needed.10/1/25 - The medical record was updated to include a diagnosis of multiple sclerosis.12/13/25 - A quarterly Minimum Data Set (MDS) assessment documented in GG0120 Functional Abilities that R109 was dependent, with helper doing all of the effort and the resident doing none of the effort to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity. The assessment documented R109 was dependent for eating, oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The assessment further documented in GG0170 Mobility that R109 was dependent for roll left and right, sit to lying, lying to sitting on side of bed, bed-to-chair transfers, and tub/shower transfers.1/5/26 - A facility collected statement written by E23 (CNA) documented during the 0615 check and change [R109] was noted to have a large liquid bowel movement. [E10 (CNA)] and I began to assist [R109]. [E10] pulled [R109] towards her (to the left side) and then rolled her onto her right side (towards me) to position her in the middle of the bed. [E10] removed the soiled brief and cleaned [R109] off, then walked the soiled brief to the linen/trash cart which was located at the entrance of the door to toss it away. [R109] continued to have diarrhea, I turned to grab a new brief and gown off the chair, which was located right behind me. As I turned back around, I noticed [R109] falling from the bed, hitting her head on the drawer of the nightstand. While falling, [R109] continued to actively pass a large amount of liquid stool, I called out for help and [E10] turned around to assist me. The supervisor was notified.1/5/26 at 6:49 AM - A progress note documented this nurse was called to the room it was noted that [R109] was laying on the floor on her back . [R109] is not able to verbalize what happen. In the process of doing personal care there were two aids present. One aid stated that she turned to place dirty laundry in the basket and the other aid turned to get her night gown off the chair. The bed was at waist level and R109 was lying on her right side when [R109] fell off the bed onto the floor. She had a deep laceration to her left temple. There was minimal red drainage. [R109] did not display [signs and symptoms] of pain. The On-call doctor was notified, and resident was sent out to get sutures to the open wound. [R109's] family member was also notified.1/5/26 - A facility collected statement by E10 documented After providing care for [R109] I stepped away to put the dirty linen in the linen basket located at the threshold of the room door. When I turned back into the room, I did not see the resident in the bed. She was on the floor. I called for help.1/5/26 - The facility reported incident documented that at approximately 6:30 AM resident rolled out of bed. RN assessment completed a laceration to the left forehead was noted first aid applied, neuro checks initiated. Family and NP notified. Resident sent to ED for evaluation and treatment.A care plan was revised on 1/6/26 that included interventions provide adequate lighting; and fall mats on floor at bedside while in bed perimeter mattress to bed, Date Initiated: 1/6/26.1/7/26 - A progress note in R109's clinical record written by E19 (NP) documented in a follow up visit that Patient was sent to the ED s/p fall out of bed with left forehead laceration. Per ED notes Reportedly, patient was being changed in bed by nursing home staff and somehow slipped out of bed hitting her forehead.1/9/26 - A 5 day follow up from the facility documented that R109 Loss of balance r/t underlying medical condition - COVID causing increased weakness and inability to hold side lying position further compromised by dx of muscle spasms and multiple sclerosis. The staff interview revealed that, the resident rolled out of bed to the floor. RN assessment completed, and the resident was noted with a laceration to the left side of her forehead. First aid was rendered, and the resident was transferred to the ER for further evaluation. NP and family were notified. The resident was seen and examined at the ER, and all tests completed were negative for any additional injury related to the fall. The resident is an assist of x2 for bed mobility, and per the investigation findings, the resident was provided care utilizing two staff members prior to resident rolling OOB. After care provided, the resident was placed on her side in secure position. Staff was still present in the room although was unable to physically prevent the resident from rolling from bed to the floor. Both CNAs are familiar with the resident as they were her routine caregivers. The resident returned from the hospital post evaluation with sutures to laceration on forehead. Therapy was consulted to evaluate post return. Safety measures were reassessed. Interventions: Perimeter mattress, Fall mats, PT eval.5/8/26 9:20 AM - During an interview with E10 (CNA), E10 revealed staff were providing incontinent care to R109 when additional linen was needed due to continued loose stool and the linen cart was positioned near the doorway. E10 stated R109 was positioned in the bed at approximately waist height and was unable to reposition herself or assist with movement. E10 further stated R109 required two-person assistance for care and positioning. E10 stated one CNA was positioned on the opposite side of the bed while care was being provided and additional linen was obtained due to continued diarrhea. E10 stated staff attempt to gather needed supplies prior to beginning care; however, additional linen was needed during the care activity due to the resident's condition. E10 stated staff try not to leave bedside during care activities. E10 stated the incident happened suddenly and E10 did not directly observe the fall; however, the other CNA observed R109 fall from the bed. E10 stated precautions for R109 included two-person assistance and maintaining the resident in an upright position related to the tracheostomy. E10 further stated staff had discussed the mattress following the incident, including a control button related to mattress inflation and deflation, and stated there had not been prior in-service education regarding the mattress function. E10 stated staff immediately notified the nurse and supervisor following the incident.Despite the facility's investigation indicating R109 had been placed in a safe position and centered in the bed, record review and staff interviews confirmed R109 continued to receive incontinent care related to ongoing diarrhea at the time of the incident. Staff interviews revealed R109 had not yet been dressed and incontinent care activities were ongoing when the fall occurred. Additionally, interview statements contained varying accounts regarding the resident's positioning immediately prior to the fall, including documentation that R109 was positioned side-lying as well as statements that the resident had been centered in the bed. Regardless of the exact positioning, the resident remained dependent on staff and continued to require two-person assistance and supervision during the care activity.5/8/26 at 1:08 PM - During an interview on E4 (CNA) stated that residents requiring two-person bed mobility require one staff member on each side of the bed during care. E4 further stated that if one staff member needed to step away, the resident should first be returned to a safe position in the bed and the bed lowered prior to staff leaving bedside. E4 stated staff received education regarding fall prevention through demonstrations and in-person training.5/8/26 at approximately 1:15 PM - During an interview with E24 (Nurse Educator) confirmed the above and E24 provided state agency with documentation of a training on 12/3/25 that documented Education for all staff that transfer/care status must be followed at all times if a resident requires a 2 person assist, they must not provide care/transfer alone. When asked what you would do if you had to step away during a two-person activity E24 confirmed that you would return the resident to a safe position move to the center of the bed, by lowering the bed to the floor. Additionally, E24 provided documentation on an Inservice initiated on 1/5/26. When providing care for resident on low air loss mattress, ensure in STATIC mode prior to providing care and resident is in the middle of the bed.5/11/26 at 9:38 AM - During an interview on E2 (Director of Nursing) stated that one aide stepped away from the bedside to place soiled linen in the linen cart outside the room while the second aide turned away from the resident to retrieve clothing. E2 confirmed the bed remained waist high during the care activity. E2 stated the facility believed R109's diagnoses, including multiple sclerosis with spasticity and COVID diagnosis, contributed to the fall.5/11/26 - During interviews conducted on E11, E12, and E13 (CNAs) stated that residents requiring two-person bed mobility require two staff members at bedside during care. Staff further stated that if one caregiver needed to leave or step away from the bedside, the resident should first be repositioned safely in the center of the bed and the bed lowered prior to staff stepping away.5/8/26 and 5/11/26 - Attempts were made during the survey to interview E23 (CNA); however, those attempts were unsuccessful.5/11/26 3:20 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R30) out of three residents reviewed for quality of care, the facility failed to ensure care/treatment in accordance with professional standards of practice. Review of R30's clinical record revealed:4/1/23 - R30 was admitted to the facility. 3/8/26 10:48 AM - An SBAR (provider communication note) documented that R30 was observed with right hip discomfort and swelling noted. The SBAR also documented the provider was notified and awaiting a return call. 3/8/26 3:22 PM - A telephone physician's order for R30 documented diagnostic imaging x-ray of bilateral hips with two views. 3/8/26 8:35 PM - A radiology results report documented that x-ray was obtained and completed at 5:03 PM on 3/8/26. The results indicated and acute fracture of R30's right hip. 3/8/26 11:09 PM - A nursing progress note documented that R30 had a positive fracture to the right hip and was sent to the hospital for further evaluation. 5/8/26 10:13 AM - At this time multiple attempts were made to contact E28 (LPN) to determine the time line of events regarding R30's change in status and were unsuccessful. 5/8/26 10:24 AM - During an interview, E14 (CNA) stated when providing care to R30 on 3/8/26 she noticed R30 was showing signs and symptoms of pain when turning during incontinence care. E14 stated that R30's right hip was not sitting evenly with the left hip when she was laying supine in the bed and that the resident was grimacing while receiving care. E14 stated she reported her observations to the nurse on duty after completing care. 5/8/26 10:51 AM - During an interview, C2 (Technician) confirmed they [mobile diagnostic imaging] received the physician's order for x-ray at 3:22 PM on 3/8/26, x-ray was completed at 5:03 PM, and the results were sent to the facility at 8:35 PM on 3/8/26. 5/8/26 12:28 PM - During an interview, E2 (DON) confirmed that R30 had a positive x-ray for right hip fracture and was sent to the hospital for treatment. It was unclear based on interview and record review why the facility sent R30 to the hospital 15 hours after change in condition was observed. This resulted in R30 not receiving care in a timely manner. 5/11/26 3:20 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R30) out of five residents reviewed for abuse, the facility failed to report an injury of unknown source to the State Agency within the required timeframe. Findings include:Review of R30's clinical record revealed:4/1/23 - R30 was admitted to the facility.3/8/26 1:00 PM - A facility reported incident documented that R30 had an injury of unknown origin determined by a positive x-ray report of a fractured right hip.3/8/26 8:35 PM - A Radiology Results Report documented an acute fracture to R30's right hip. 3/9/26 12:59 AM - A facility reported incident was submitted to the State Agency 12 hours after incident occurred. 5/8/26 12:28 PM - During an interview, E2 (DON) confirmed that the aforementioned report was not submitted to the State Agency within the appropriate timeframe. 5/11/26 3:20 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R153) out of six residents reviewed for pharmacy services, the facility failed to provide pharmaceutical services to meet the needs of each resident. Findings include: Review of R153's clinical record revealed:1/9/26 - R153 was admitted to the facility. 1/9/26 - A physician's order documented nafcillin sodium (antibiotic) in dextrose intravenous solution 2GM/100mL: Use 2 gram intravenously every 8 hours for pneumonia for 15 days. 1/10/26 - A review of the January MAR documented H on the aforementioned nafcillin order for 12:00 AM and 8:00 AM dose due to medication not available from pharmacy. The MAR lacked evidence of a hold order for the dose on 1/9/26 at 4:00 PM. 1/13/26 - A physician's order documented cefazolin sodium injection solution 2 GM: Use 2 gram intravenously three times a day for endocarditis and bacteremia prophylaxis. 1/13/26 11:41 PM - A progress note documented that cefazolin was on order from the pharmacy. The MAR documented 8 for the 10:00 PM dose with the aforementioned progress note. 5/8/26 12:10 PM - During an interview, C1 (Pharmacy) confirmed that the nafcillin was delivered on 1/10/26 and the cefazolin was delivered on 1/14/26 by the pharmacy currier. 5/8/26 1:36 PM - During an interview, E26 (LPN) stated the admitting nurse was responsible for calling pharmacy regarding any new medication orders from admission. E26 stated at times medications would have to be requested STAT (immediately) to receive them from pharmacy quickly. E26 stated she did not recall if there was a delay in receiving R153's IV medications. 5/8/26 1:49 PM - During an interview, E27 (LPN) stated she assisted in admitting R153 to the facility and cannot recall if there was any issue receiving R153's medications. E27 stated they do have medication on site in the back up pharmacy if its needed, but it has limited options of medications. 5/8/26 2:02 PM - During an interview, E2 (DON) stated the facility was having issues with the pharmacy and deliveries delayed for the medications. E2 confirmed that R153's delay in delivery was around the time the facility was experiencing delays, which resulted in the facility switching locations of pharmacy delivery. 5/11/26 1:30 PM - During an interview, E19 (NP) stated that the antibiotics R153 were ordered by the provider at the hospital and would have had to be ordered from pharmacy. E19 confirmed that he approved medications to be held due to the delay in delivery from pharmacy. 5/11/26 3:20 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R644) out of eleven residents, the facility failed to ensure that R644 was free of medication error. On 9/13/24, R644 was inadvertently given the incorrect medications (amlodopine 10mg, benzapril 40mg, Coreg 25 mg and selevamer 800mg). This medication error resulted in harm as R644's blood pressure significantly dropped and she was sent emergently to the hospital for evaluation and treatment. This harm is being cited as past non-compliance. Findings include: Facility's Medication Administration policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Procedure: 3. Identify resident by photo in the MAR (medication administration record) . 10. Compare medication source with MAR to verify resident name, medication name, form, dose, route and time . Rev. 1/2025 Review of R644's clinical record revealed: 9/12/24 - R644 admitted to the facility with diagnoses including but not limited to, heart failure and chronic obstructive pulmonary disease. 9/13/24 9:30 AM - E23 (staff RN) documented in R644's EMR progress notes, Resident's vital signs checked and resident noted to be hypotensive 65/26 in LUE (left upper extremity) . 9/13/24 9:37 AM - C6 (EMT) documented in R644's prehospital care report, . The staff relayed the patient [R644] was given amlodipine 10 mg, benzaprine 40 mg, Coreg 25 mg and sevelamer 800 mg this morning at 8:20 AM. The staff relayed that those medications are not prescribed for the patient and the patient was suppose to be given amlodipine 5 mg, clonidine 0.1mg, furosemide 40 mg and losaratan 100 mg. The staff relayed that they checked the patient's blood pressure an hour after the medication mix-up and found the patient to be hypotensive and 911 was activated . 9/13/24 9:48 AM - R644's blood pressure (BP) documented on the prehospital care report as 50/20. 9/13/24 9:53 AM - R644's blood pressure (BP) documented on the prehospital care report as 50/26. 9/13/24 3:25 PM - C7 (hospital ER DO) documented on R644's ER visit summary, .Reason for visit: drug overdose, Diagnosis: hypotension .You were seen here in the emergency room for your low blood pressure after taking the wrong medication. We did an evaluation that included blood work and gave you IV fluids .Blood pressure 110/51 . 9/14/24 1:31 AM -E27 (LPN) documented in R644's EMR progress notes, .Resident returned from [hospital] via stretcher accompanied by 2 EMTs . VS 132/78 (BP), 72 (HR), 18 (Respirations), 97.9 (temperature), 98 (pulse oximetry) on O2 (oxygen) . R644 spent approximately 16 hours in the hospital ER receiving IV fluids and having her vital signs monitored. R644 returned to the facility on [DATE] at 1:31 AM. 9/18/24 - R644's admission MDS documented a BIMS score of 14, which was reflective of normal cognition. 4/11/25 2:03 PM -During a telephone interview, C6 confirmed that E27 (LPN) admitted to accidentally giving R644 her roommate's medications. 4/11/25 3:12 PM - A review of the facility's incident investigation provided a typed and signed statement from E27 (staff LPN) stating,Around 8:15 AM, I pulled R644 roommate's medications. I was looking at the name in the room, there was only one name in there. I took her blood pressure, and it was normal. I called her [R644's roommate's name]. I said to R644, 'I have your medication' and she said I need my medication in pudding. I did not know she [R644] was hard of hearing. I gave medication and then I went to the roommate in B bed and that's when I realized I gave A bed, B bed's medication. I looked at the arm bands after I realized I made a mistake. At 8:20 AM the unit manager contacted the provider and provider stated to recheck the vital signs in a n hour. I re-checked her in about an hour later. Her blood pressure was 74/55 automatic blood pressure machine and then re-checked again still low. At 9:21 AM the unit manager contacted the provider and received orders to send to the ER for evaluation. 4/14/25 11:30 AM - An attempt to contact E27 for an interview was unsuccessful. 4/16/25 3:30 PM - A review of all the documentation of the corrective action plan completed by the facility included: -Timely reporting to the state Agency -Additional education regarding medication administration for E27 -Additional monitoring of E27 including a 3-person med pass with the Pharmacist to verify her knowledge of med administration and shadowing during all med passes until she was cleared for normal duty. E27 was terminated on 1/1/25 for failing to perform the requirements of the job. -Notification of the family informing them of the medication error It was verified by the surveyor that the corrections were completed as of 9/18/24 through document review and interview. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in manner that prevents food borne illness to the residents. Findings include: 1. 4/8/25 8:20 AM - Observation and inspection of the Sierra Unit nourishment refridgerator revealed that it contained a sandwich, container of pickles and a container of sliced tomatoes that were undated and unlabeled. The finding was immediately confirmed by E20 (LPN) unit manager. 2. 4/8/25 11:28 AM - During a dining observation in the main dining room, E21 (DA) was observed wearing gloves and holding a paper meal ticket in the right hand. At 11:33 AM, E21 left the dining room and entered the kitchen to communicate with kitchen staff. E21 then returned to the dining room at the food service counter still holding the same meal ticket paper in right hand, touched her nose, adjusted her face mask with the left hand then reached into the bag of bread with the same left hand to prepare a sandwich. The surveyor intervened, and E21 put down the meal ticket, and discarded both gloves and donned a new pair of gloves with out performing any hand hygiene. E21 immediately confirmed the findings and discarded the slice of bread. 3. 4/10/25 11:36 AM - 11:48 AM - During a follow up visit to inspect the facility kitchen the following was observed: - Eight plates removed from plating area contained food debris. - Two dessert cups removed from dish rack contained food debris. - Meat stored on the top most shelf in the refrigerator thawing over vegetables. - Visible dust on the fan in the dish area. E22 (FSD) immediately confirmed the findings. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on observation and interview, it was determined that for two out of three resident units the facility failed to provide a clean and homelike environment. Findings include: 4/15/25 10:23 AM - During an observation in room [ROOM NUMBER] Seaside Unit, the bathroom door frame had multiple areas of chipped paint. The wall to the right of the bathroom had several scrapes and an exposed metal plate was observed on the left corner of the bathroom wall. 4/15/25 10:32 AM - During an observation in room [ROOM NUMBER] Seaside Unit, the wall to the right of the bathroom had multiple scrapes and black marks. 4/15/25 10:41 AM - During an observation in room [ROOM NUMBER] Seaside Unit, the bathroom wall facing the toilet had two areas of missing plaster just above the baseboard. 4/15/25 10:52 AM - During an interview, E7 (CNA) stated she has worked on the unit for five years and was aware of the rooms in question the needed repairs. When asked how long the rooms have been in a state of disrepair? E7 responded way over six months close to a year. 4/15/25 11:05 AM - During an interview, E8 (Maintenance Director) confirmed the repairs in rooms [ROOM NUMBER]. E8 revealed they did the hallway repairs first. When asked how long he had been aware of the repairs in resident rooms, E8 responded it's been a long time, close to a year. 4/16/25 2:50 PM - During an observation in room [ROOM NUMBER] Sierra Unit, the bathroom door frame had multiple areas of chipped paint.The wall to the right of the bathroom had several areas of missing plaster and multiple scrape marks. 4/16/25 2:55 PM - During an observation in room [ROOM NUMBER] Sierra Unit, the bathroom door frame had multiple areas of chipped paint.The wall to the right of the bathroom had several areas of missing plaster and multiple scrape marks. 4/16/25 3:02 PM - During an interview, E8 demonstrated how to retrieve work orders. E8 stated that any staff member can place a work order online. E8 also maintains a worklog on his cell phone and confirmed there are no current orders for painting or repairs to resident rooms. 46988 4/10/25 2:20 PM - An observation of the Sierra unit tub room noted tiles missing on shower floor approximately 3L x 4W, a dark black substance noted in the grout of tile on the floor, and dirt and debris noted all over floor close to entrance. 4/11/25 10:04 AM - An observation of the Sierra unit tub room noted tiles missing on shower floor approximately 3L x 4W and a dark black substance noted in the grout between the tiles on the floor. 4/14/25 11:45 AM - An observation of the Sierra unit tub room noted tiles missing on shower floor approximately 3L x 4W and a dark black substance noted in the grout between the tiles on the floor. 4/15/25 1:45 PM - An observation of the Sierra unit tub room noted tiles missing on shower floor approximately 3L x 4W and a dark black substance noted in the grout between the tiles on the floor. 4/16/25 9:43 AM - In an interview with E43 (Housekeeping) confirmed that the tub room is cleaned daily and sometimes twice daily. E43 confirmed the tiles have been broken and maintenance has been notified. Additionally, E43 confirmed the dark substance noted in the grout of the tiles on the floor. 4/16/25 9:49 AM - In an interview with E42 (Maintenance) confirmed that no work order was in the system regarding the missing tiles to be replaced in the Sierra Unit tub room. E42 stated he will take care of it today. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for five residents (R91, R119, R120, R130, and R440) out of forty three sampled residents, it was determined that for R440 and R130 the facility failed to implement care plan interventions. For R12, the facility failed to hold a quarterly care plan meeting. For R91, R119, and R120 the facility failted to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. Findings include: 1. Review of R440's clinical record revealed: 4/1/25 - R440 was admitted to the facility with the diagnosis of syndrome of inappropriate antidiuretic hormone secretion (a condition in which high levels of a hormone cause the body to retain water). 4/2/25 3:00 PM - A physician's was order written for R440 that documented Fluid restriction 1200 milliters a day. 4/2/25 - R440's care plan that was initiated on 4/2/25 documented potential/alteration in nutritional status r/t (sic) need for mechanically altered, fluid restricted diet. The care plan lacked evidence the resident was resistive to the physician's order for a fluid restrictive diet. 4/8/25 10:09 AM - An observation revealed that R440 had a water pitcher sitting on the nightstand next to the bed filled with ice water, and a large drinking mug sitting on the over bed table next to R440's bed filled with liquid. [R440] stated, oh that has Gatorade in it. 4/9/25 8:53 AM - A second observation revealed that R440 had a water pitcher and two other large drinking mugs at the bedside. 4/9/25 9:15 AM - An interview with E16 (RN, UM) confirmed that R440 does not comply with fluid restrictions. E16 stated, [R440's] wife brings in additional fluids for him, we have educated them we are keeping a close eye on it and I'm going to check to see if the care plan was updated to reflect this problem, if not I'm updating it now, we are going to stay on top of that. 4/9/25 - R440's care plan, revised 4/9/25, documented resistive/noncompliant with treatment/care related to disbelief in value of treatment (resident and family has been educated numerous times on risks associated with not following fluid restrictions) interventions included provide education about risks of not complying with therapeutic regimen, provide education to patient/family. Cross Refer, F677 example 1 2. Review of R130's clincial record revealed: 3/7/25 - R130 was admitted to the facility. 3/10/25 - A review of R130's care plan for ADL self-care deficit documented [R440's] will be clean, dressed and well-groomed daily to promote dignity and psychosocial wellbeing for ninety days. R440's interventions included assist with daily hygiene, grooming, dressing, oral care, and eating as needed. 3/13/25 - R130's admission MDS assessment documented the resident was severely cognitively impaired and required substantial maximum assistance for personal hygiene and grooming. 4/8/25 9:26 AM and 4/11/25 11:07 AM - Observations confirmed that R130's nails on both hands were long, with dark encrusted debris underneath each nail. E16 (RN UM) confirmed that R130 needed nail care. 4/11/25 11:07 AM - E16 (RN UM) stated Well last week the CNA was trying to do [R130's] nail care and she ecame combative so it couldn't get done. E16 also confirmed R130's ADL care plan had not been revised to reflect refusal of nail care. E16 stated, No she has not been care planned for refusing nail care. 40260 3. Review of R119's clinical record revealed: 5/13/24 - R119 was admitted to the facility. 5/20/24 - An admission MDS was completed. 5/22/24 - The admission Resident Care Conference Attendance Sheet for R119's post admission care plan meeting lacked evidence of attendance or input from a physician, a registered nurse, a CNA, or dietary staff. 4/17/25 8:34 AM - In an email communication, the surveyor notified E1 (NHA) and E2 (DON) that there was a lack of evidence of input by all IDT members at the initial care plan meeting. E1 responded that the facility will ensure participation from these parties immediately and ongoing in all care plan meetings, including the initial meetings. 4. Review of R120's clinical record revealed: 5/14/24 - R120 was admitted to the facility. 5/20/24 - An admission MDS was completed. 5/20/24 - The admission Resident Care Conference Attendance Sheet for R120's post admission care plan meeting lacked evidence of attendance or input from a physician, a registered nurse, a CNA, or dietary staff. 4/17/25 8:34 AM - In an email communication, the surveyor notified E1 (NHA) and E2 (DON) that there was a lack of evidence of input by all IDT members at the initial care plan meeting. E1 responded that the facility will ensure participation from these parties immediately and ongoing in all care plan meetings, including the initial meetings. 46988 5. Review of R91's clinical record revealed: 2/27/25 - R91 was admitted to the facility. 3/5/25 - An admission MDS was completed for R91. 3/7/25 10:00 AM - The admission Resident Care Conference Attendance Sheet for R91's post admission care plan meeting lacked evidence of attendance or input from a physician, a CNA, or dietary staff. 4/14/25 11:57 AM - An interview with E5 (SW) confirmed that all members of the interdisciplinary team were not present or provided input on 3/7/25 for R91's care plan meeting. E5 confirmed input from the physician, CNA, and dietary was not provided. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for two (R14 and R639) out of twelve residents reviewed for infection control, the facility failed to initiate and maintain appropriate precautions per CDC guidelines. Additionally the facility failed to follow standard precautions. Findings include: CDC's Infection Control Appendix A: Type and duration of Precautions Recommended for Selected Infections and Conditions .Multidrug-resistant organisms, infection or colonization (e.g., MRSA, VRE, VISA/VRSA, ESBLs, resistant S.pneumoniae) Contact + Standard . February 7, 2025 Facility's Infection Prevention and control Program Policy: .Policy Explanation and Compliance Guidelines: .5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Rev 1/2025 Facility's Enhanced Barrier Precaution Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced Barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). 1.Review of R14's clinical record revealed: 12/13/20 - R14 was admitted to the facility with diagnoses including but not limited to, multiple sclerosis, seizures and S/P colostomy. 10/5/23 - 10:23 AM - C3 (consultant medical director) documented in R14's progress note, .History of present illness: Patient is a [AGE] year old male with past medical history significant for HTN (hypertension) . colostomy . 4/1/24 - New EBP guidelines from CMS were effective in long term care facilities. 11/22/24 - C2 (consultant NP) initiated an order in R14's EMR, Enhanced Barrier precautions related to history of ESBL urine, colostomy. Every shift for monitoring. The facility failed to initiate EBP for R14 until eight months (from 4/1/24 to 11/22/24) after the new guidelines were mandated. 4/16/25 - 12:01 PM - During an interview, E2 (DON) confirmed that R14 has had a colostomy since he has been in the facility. 2. Review of R639's clinical record revealed: 6/21/24 - R639 was admitted to the facility with diagnoses including but not limited to, chronic obstructive pulmonary disease. 10/3/24 - 5:37 PM - C4 (hospital MD) documented in R639's discharge summary, Principal diagnosis: MRSA pneumonia . due to positive MRSA swab . discharge medications: .linezolid 600 mg (milligram) tablet- take 1 tablet by mouth 2 times a day for 20 days . 10/3/24 - C2 (NP) entered order in R639's EMR stating, linezolid tablet 600 mg - give 1 tablet by mouth every 12 hours for infection of lungs for 20 days. 4/16/25 - 10:35 AM - A review of R639's EMR revealed that there was not a contact precautions order in effect while R639 was being treated for MRSA pneumonia with linezolid (antibiotic to treat MRSA pneumonia). The facility failed to initiate contact precautions for R639 while he was being treated for MRSA pneumonia from 10/3/24 to 10/24/24. 47114 4/8/25 6:16 AM - A random observation revealed a clear plastic trash bag with dirty briefs and gloves was sitting on the floor in front of room [ROOM NUMBER] which had signage on the door that indicated EBP (Enhanced Barrier Precautions). 4/8/25 6:20 AM - E26 (CNA) was observed leaving room [ROOM NUMBER] wearing disposable gloves. E26 picked up the trashbag and proceeded to walk across the hallway to room [ROOM NUMBER] another room with EBP signage on the door, placed the trash bag on the floor and entered the room wearing the contaminated gloves on both hands. 4/8/25 6:41 AM - During an interview E2 (DON) observed the trash bag was sitting on the floor in the doorway of room [ROOM NUMBER]. E2 stated, No this should not be it should go directly to the biohazard room. E2 picked the trash bag up off the floor, E26 opened the door to leave room [ROOM NUMBER] wearing gloves, E2 stopped E26 in the hallway and educated the CNA on wearing gloves, hand washing and that trash should not go from room to room and is to be taken to the biohazard room for disposal. The trash was disposed off by E2. 4/8/25 8:31 AM - An additional observation of room [ROOM NUMBER] with EBP signage revealed a clear plastic bag with dirty linen and a bag with briefs and other trash were sitting on the floor inside of room [ROOM NUMBER]. E16 (RN, UM) entered room [ROOM NUMBER] and picked the bags up off the floor. E16 confirmed and stated, Yes I know the trash bags being left on the floor is an infection control concern. E16 proceeded to take the bags to the biohazard room for disposal. 4/17/25 1:45 PM -Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview it was determined that for one (R188) out of three residents reviewed for discharge the facility failed implement a discharge planning process that prepared the resident/RP to effectively transition to post-discharge care. Findings include: The facility policy on transfer and discharge undated indicated, Anticipated transfers or discharges - A post discharge plan of care that is developed with the participation of the resident and the residents representative which will assist the resident to adjust to his or her new living environment. Review of R188's clinical record revealed: 5/2/24 - R188 was admitted to the facility. 5/3/24 - A care plan for discharge documented that R188 expressed wish for discharge to home. 5/3/24 12:34 PM - A social work progress note written by E6 (SW) in R188's clinical record documented, Resident is short term care at our facility. Resident will be discharged back to prior living arrangement once therapy is completed. The note did not document R188's actual discharge date . 5/9/24 - An admission MDS assesment documented that R188 was admitted with plans to discharge to the the community. 6/1/24 - An Eligibility Verification Notice was provided to the facility by R188's insurance that indicated the resident had 0 days remaining for nursing home stay as of 5/26/24 6/3/24 11:15 AM - A SNFABN notice was read over the telephone to R188's RP. 6/3/24 11:52 AM - A social work progress note in R188's clinical record written by E5(SW) documented, [R188] had his discharge plan meeting today with the interdisciplinary team along with [responsible party]. E5 (SW) informed resident and family member of 100th day 5/26/24 . SW also inform resident and family member the facility just notified of discharge to home on 6/4/24 for the resident. SW also informed resident and family member of private pay cost of $506.00. Family member and resident have refused to pay private rate. SW did inform resident and family once bill has been received call the number to file a dispute. 6/4/24 - A discharge return not anticipated MDS assessment was completed for R188 that documented the discharge was planned. 4/10/25 2:38 PM - During an interview E5 (SW) confirmed that R188 and their RP were notified of their discharge date on 6/3/24 giving one day to prepare for R188's transfer home. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interviews, it was determined for two (R40 and R50) out of forty-three sampled residents, the facility failed to ensure the MDS was accurate. Findings include: 1. Review of R40's clinical record revealed: 12/15/15 - R40 was admitted to the facility. 9/10/24 - A quarterly MDS assessment documented R40 was experiencing verbal behavioral symptoms directed towards others for one to three days during the review period. 9/2024 - A CNA behavioral flow sheet documented R40 had behaviors for five days from 9/3/24 to 9/10/24. 12/10/24 - A quarterly MDS assessment documented R40 was experiencing verbal behavioral symptoms directed towards others for one to three days during the review period. 12/2024 - A CNA behavioral flow sheet documented R40 had behaviors for five days from 12/3/24 to 12/10/24. 4/17/25 10:15 AM - During an interview, E46 (RN) confirmed that R40 had an increase in verbal behaviors specifically during shift change prior to R40 moving to a different unit. 4/17/25 10:30 AM - During an interview, E5 (SW) confirmed that the MDS data was not accurate for R40 during the September 2024 and December 2024 review. 2. Review of R50's clinical record revealed: 7/25/23 - R50 was admitted to the facility. 10/15/24 - A quarterly MDS assessment documented that R50 was experiencing physical behavioral symptoms towards others and other behavioral symptoms not directed at others for one to three days during the review period. 10/2024 - A CNA behavioral flow sheet documented R50 had behaviors for five days from 10/8/24 to 10/15/24. 1/15/25 - A quarterly MDS assessment documented that R50 was experiencing behaviors on zero days during the review period. 1/2025 - A CNA behavioral flow sheet documented R50 had behaviors for four days from 1/8/25 to 1/15/25. 4/17/25 10:30 AM - An interview with E5 (SW) confirmed that the MDS data was not accurate for R50 during the October 2024 and January 2025 review. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R136) out of forty-three sampled residents, the facility failed to complete a comprehensive assessment after R136 had a significant change in status. Findings include: Review of R136's clinical record revealed: 11/7/24 - R136 was admitted to the facility. 12/6/24 - R136 was admitted to hospice care. 1/2/25 - C2 (consultant NP) entered an order into R136's EMR, Hospice [local hospice service] every shift. This was twenty-seven days after R136 was admitted to a hospice service. 4/9/25 1:44 PM - A review of R136's EMR MDS schedule revealed there was no significant change MDS completed within fourteen days of R136's hospice admission. 4/10/25 11:02 AM - In a telephone interview, C1 (hospice office staff) confirmed. [R136] was admitted to our hospice service on 12/6/2024. 4/10/25 11:27 AM - During an interview, E4 (Business Office Manager) confirmed, [R136] went on hospice care on 12/6/24. 4/10/25 1:23 PM - During an interview, E11 (RNAC) confirmed that R136's MDS for a significant change was completed on 1/3/25, as soon as the MDS office became aware that R136 was placed on hospice services. We were not aware of the change. We did the mandatory MDS assessment as soon as we were notified. 4/11/25 9:36 AM - Review of the Ombudsman Transfer/Discharge list for December 2024 revealed R136 was listed as converting to hospice on 12/6/24. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R79) out of five residents reviewed for hospitalizations, the facility failed to notify R79's responsible party in writing of the reason for transfer to the hospital. Findings include: Review of R79's clinical record revealed: 11/6/20 - R79 was admitted to the facility, with diagnoses including but not limited to, dementia. 4/1/25 - R79's quarterly MDS documented a BIMS score as three, which reflected severe cognitive impairment. 4/5/25 9:38 PM (Saturday) - E9 (LPN) documented in R79's EMR progress note, .Resident vomited again a large amount of brown colored vomit. Resident with change in LOC .order to send to ER via 911 .Emergency contact [F1] notified. 4/14/25 1:32 PM - A review of R79's EMR revealed F1 (R79's responsible party) was listed as the Emergency Contact #1. 4/15/25 10:14 AM - A review of R79's transfer notice, dated 4/7/25 (Monday) and signed by E10 (Admissions Director), failed to document to whom the notice of transfer was presented. 4/15/25 12:03 PM - During an interview, E10 stated, The bed hold and transfer/discharge notification form is housed in the social work department. They fill in the form and print it out. I then call the family member and make sure they know the resident has left the facility. I go over the bed hold policy based on their insurance. I date and time the notification and it gets scanned I to the resident's EMR . No, I don't mail the notification form to the family member. The facility failed to notify in writing R79's transfer to the hospital. Additionally, E10 confirmed that a copy of the notification form was not mailed to R79's responsible person. Additionally, the notification scanned into R79's EMR stated reason for transfer/discharge: ER. R79 was transferred to the hospital 4/5/25 for change in LOC and vomiting large amounts of brown secretions. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interviews, for one (R112) out of five sampled for abuse, it was determined that R112 was not free from involuntary seclusion. Findings include: Cross refer F684 and F880. Review of R112's clinical record revealed: 7/30/24 - R112 was admitted to the facility. 8/18/24 - A SBAR (physician's communication tool) documented that R112 had a rash on both arms and upper thighs. 8/18/24 3:15 PM - A nursing skin observation tool documented R112 had the following skin conditions noted: right antecubital rash, left antecubital rash, bilateral thighs front. 8/27/24 - A care plan documented that R112 was placed on isolation precautions related to scabies. 8/27/24 3:12 PM - A physician's order documented that R112 was on contact isolation due to scabies for fourteen days. R112's 8/24 MAR documented that Ivermectin oral tablets and Permethrin external cream for scabies were started on 8/29/24. 9/3/24 - A physician (C5 NP) progress note documented that R112 was seen and examined for a scabies. C5 documented for R112 to continue on Permethrin external cream to skin at bedtime for seven days, then for two days a week, and to continue isolation precautions. 9/16/24 - A physician (C5 NP) progress note documented that R112 requested to be seen and wanted to be taken off isolation precautions. The progress note documented that the rash to upper extremities had resolved and that the rash was now on lower extremeties and inner thighs. E21 documented for R112 to continue on Permethrin external cream and added benadryl and hydrocortisone creams regimen for itching. R112 was to continue on contact isolation precautions. 10/4/24 - A physicians (C5) progress note documented R112 was seen for a follow up for scabies and that a new linear rash was noted on his abdomen. It was noted that the rash had improved with the applications of Permethrin cream. R112 was to continue on isolation precautions. 11/9/24 - A physicians order was written for R112 to have a consult with dermatology related to scabies. 11/13/24 - A physician progress note documented that R112 was seen for a follow up post dermatology consult, and dermatology diagnosed R112 with atopic dermatitis (generalized rash). Per dermatology, R112's rash was unrelated to scabies and contact isolation discontinued per order. 4/8/25 6:48 AM - An interview with R112 revealed that R112 was on contact isolation for 78 days related to a misdiagnosed scabies outbreak. R112 stated I felt like a prisoner being confined to this room all that time and no one would listen to me until I saw the dermatologist. R112 stated that he did not receive showers until sometime in October. 4/14/25 10:48 AM - An interview with E38 (CNA) confirmed that R112 was on isolation precautions and unable to shower from August 27, 2024 to October 16, 2024. 4/15/25 10:30 AM - During an interview with C2 (NP) and C5 (NP), C2 stated that the providers do not determine how long a resident is on isolation precautions, that the facility mandates the timeframe. C2 and C5 confirmed that they did not refer to the CDC guidelines for the treatment of scabies for R112. Additionally, C2 stated that R112 had requested a meeting with the providers to discuss why he was still on isolation precautions, and C2 confirmed that once R112 was seen by dermatology, that R112's isolation precautions were removed. 4/15/25 11:12 AM - An interview with E1 (NHA) confirmed that the process of determining isolation precautions is a collaborative effort between the IDT team which includes input from the physician's, management, and the infection control preventionist. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on a random observation and interview, it was determined that for four (R37, R69, R72, and R133) residents, the facility failed to protect personal privacy. Findings include: 4/10/25 11:08 AM - A random observation of the staff charting station on Sierra Unit with a monitor displaying resident's protected health information: - R37's admitted , admitting diagnoses, and birthdate. - R69's admitted , admitting diagnoses, and birthdate. - R72's admitted , admitting diagnoses, and birthdate. - R133's admitted , admitting diagnoses, and birthdate. 4/10/25 11:10 AM - During an interview with E3 (ADON), it was confirmed that a charting station monitor was left open, displaying R37's, R69's, R72's and R133's personal protected health information (PHI). The information was visible to anyone passing by the monitor. E3 took immediate action to close the screen and secure the PHI. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R188) out of four residents reviewed for Beneficiary Notification Review, the facility failed to ensure the resident was informed in advance of a change that occurred to their bill. Findings include: Review of R188's clinical record revealed: 5/2/24 - R188 was admitted to the facility. 6/1/24 - An Eligibility Verification Notice was provided to the facility by R188's insurance that indicated the resident had 0 days remaining for nursing home stay. 6/3/24 11:15 AM - A SNFABN notice was read over the telephone to R188's Responsible Party (RP)(R188's daughter) that explained beginning on 6/4/25 R188 and RP would be responsible to pay out of pocket for the R188's facility stay. The notice was completed by E5 (SW) and witnessed by E6 (SW). 4/11/25 8:15 AM - During an interview, E4 (BOM) confirmed that R188 and RP were not made aware of the change in billing in advance. E4 explained that the facility was made aware of R188's change in coverage on 6/3/24 and provided the SNFABN notice that same day, then charged R188 from the last date of coverage 5/26/24. 4/11/25 9:00 AM - A statement of the same date was provided to the surveyor by E4 (BOM) that indicated R188 was billed from 5/26/24 - 5/31/24 $506.00/day = $3036.00. Then billed 6/1/24 -6/3/24 $506.00/day = $1518.00 for room and board. The statement contained a projected write off of the bill dated 4/30/25. E4 stated she contacted corporate that morning and that R188 and RP would no longer be responsible for the bill. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R641) out of the seven residents reviewed for advanced directives, the facility failed to ensure that R641's' representative was included in the advanced directive acknowledgment as R641 had cognitive impairment. Findings include: Review of R641's clinical record revealed: 7/5/24 - R641 was admitted to the facility. 7/11/24 - R641's admission MDS documented a BIMS score of 11, which was reflective of moderate cognitive impairment. 4/11/25 10:05 AM - A review of R641's EMR revealed that R641's face sheet listed F4 (R641's daughter) as the emergency contact #1. The EMR also contained documentation of a signed and notarized POA with two witnesses dated from 2006 that named F4 as the sole POA for both durable medical and financial issues. 4/11/25 10:25 AM - A review of R641's admission paperwork revealed that E6 (SW) completed the Advance Directive Acknowledgment form with R641 on 7/5/24. A review of the form revealed that R641 printed her name on the signature line using a different first name and mispelling her last name, leaving a letter out of it. 4/11/25 11:04 AM - During an interview, E5 (SW Director) stated, For new admissions, we try to do the BIMS section of the MDS right away. If they come in during the evening, we try to do it the next day. A BIMS score for a person with cognitive impairment is 6 or 7. If they have a score of 10-11, then it is a judgment decision. We don't really have a cutoff score for when residents cannot make decisions. It is more of a judgment thing. There really is not any formal training for the BIMS test. It is a piece of paper that we follow. When filling out the Advance Directive Acknowledgement form, if they want more information about advanced directives, we get the ombudsman involved. 4/11/25 11:47 AM - During an interview, E2 (DON) stated, Normally, if the BIMS score is below 12, we get the family representative or POA involved in signing the paperwork. 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on observation and interview, it was determined that for one (R14) out of forty-three (43) residents in the investigative sample, the facility failed to ensure R14 was treated with respect and dignity. Findings include: 1. Review of R14's clinical record revealed: 12/13/20 - R14 was admitted to the facility. 4/8/25 8:34 AM - During an observation, E45 (CNA) knocked on R14's room door and entered the room without waiting for R14's response/permission to enter the room. 4/8/25 8:45 AM - During an observation, E44 (Central Supply) knocked on R14's room door and entered the room without waiting for R14's response/permission to enter the room. 4/8/25 9:01 AM - During an interview E44 (Central Supply) confirmed that the expectation is to knock and wait for a response to enter a resident's room. E44 confirmed that she did not wait for a response before entering R14's room. 4/8/25 9:49 AM - During an observation, E45 knocked on R14's room door and entered the room without waiting for R14's response/permission to enter the room. 4/11/25 2:16 PM - During an observation, E45 knocked on R14's room door and entered the room without waiting for R14's response/permission to enter room. 4/11/25 2:21 PM - During an interview E45 (CNA) confirmed that the expectation is to knock and wait for a response to enter a resident's room. E45 confirmed she did not wait for a response before entering R14's room.

Based on record reviewed and interview it was determined that for one (R196) out of forty-three residents sampled, the facility failed to ensure the person centered care plan included necessary interventions. Findings include: The facility policy on dialysis care last updated, January 2025 indicated, The nurse will monitor and document the status of the resident's access site. Review of R196's clinical record revealed: 2/15/25 - R196 was admitted to the facility with multiple diagnoses including kidney disease. 2/16/25 - A task was added to R196's physicians orders for blood pressure medications for staff not to obtain blood pressures on the resident's right arm. 2/18/25 - A care plan was created for R196's renal disease. Interventions for the care plan included dialysis twice a week, monitor lab and report abnormal results, observe for and report any signs of infection/leaking/dislodgement of dialysis catheter and record weights and report changes. There was no evidence that the care plan included an intervention to avoid blood pressures to the right arm due to the dialysis catheter. 2/21/25 - An admission MDS assessment documented that R196 received dialysis. 4/17/25 4:26 PM - During an interview E2 (DON) confirmed the finding. 4/17/25 5:00 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

REVISED POST IDR Based on observation, interviews and record review it was determined that for one (R110) out of two residents reviewed for pressure ulcers, the facility failed to provide care and services to prevent an avoidable deep tissue injury from developing, causing harm. Findings include: Review of R110's clinical record revealed: 7/7/23 - R110 was admitted to the facility with diagnoses including but not limited to diabetes mellitus with other circulatory complications, dementia, progressive neuropathy and stroke. 7/7/23 - A care plan, last revised 1/4/24, documented that R110 was at risk for alteration in skin integrity related to diabetes, impaired mobility and incontinence. The care plan included to notify physician and significant other of any change in skin condition, observe skin condition with activities of daily living every day and report abnormalities and turn and reposition with skin checks every two hours. 1/9/24 - A quarterly MDS for R110 documented that R110 was dependent to move from sitting to lying, lying to sitting on the side of the bed, for lower body dressing and putting on/off footwear, required moderate assistance to sit to stand and required substantial assistance (the staff does more than half of the effort) to walk 10 feet. R110 was documented to use a wheelchair with setup assistance. R100 was at risk of developing pressure ulcers with no current ulcers. There were pressure reducing devices for the chair and bed in place and ointments/medications other than to the feet being used. 3/6/24 - A review of the physician's orders revealed a treatment order for the right heel to cleanse with normal saline, air dry, apply hydrogel, calcium alginate and a clean dry dressing every day shift and as needed. The aforementioned treatment order was for R110's right heel for a diabetic foot ulcer. 3/12/24 - A nursing Braden Scale documented R110 with a score of 16 (15 - 18 is considered at risk of skin breakdown). 3/13/24 - A wound evaluation form documented a new pressure related deep tissue injury to the right, top of foot with measurements of 5 cm x 7 cm x 0 cm with 100% epithelial cells in the wound bed and the wound edges are attached. The document listed the treatment to apply skin prep and leave open to air twice a day. No color description of the wound was provided. 3/13/24 - A review of a physician's order revealed a treatment order for R110 for the right, top foot to apply skin prep and leave open to air. Do not wrap with kling. Change every day and evening shift and as needed. 3/13/24 - A treatment order for R110 for the right heel and left heel to cleanse with normal saline, air dry, apply skin prep and hydrocolloid. Do not wrap with kling. Change every Wednesday and as needed. The aforementioned treatment orders instructed staff not to use kling to wrap around R110's foot. 3/14/24 - A treatment order for R110 for the right heel to cleanse with normal saline, air dry, apply medi-honey and calcium alginate, cover with abdominal pad and wrap lightly with kling every day shift and as needed. 3/20/24 - A wound evaluation form for R110 documented the wound to the right, top of foot as a pressure related, stage 2 with measurements of 4 cm x 5 cm x 0.10 cm with 100% epithelial cells in the wound bed and the wound edges are attached. The document listed the treatment to cleanse with normal saline, apply skin prep and hydrocolloid weekly. No color description of the wound was provided. The wound inaccurately back staged from a deep pressure injury to a pressure ulcer stage 2. 3/27/24 - A wound evaluation form for R110 documented the wound to the right, top of foot as a pressure related, unstageable with measurements of 4 cm x 7 cm x 0.10 cm with 75 - 99% epithelial cells and 1 - 24% of slough in the wound bed and the wound edges are attached. There was a moderate amount of fluid from the wound. The document did not say what type of fluid. The document listed the treatment to cleanse with normal saline, apply medical grade honey and calcium alginate then cover with border gauze weekly. No color description of the wound was provided. 5/8/24 - A wound evaluation form for R110 documented the wound to the right, top of foot as a pressure related, unstageable with measurements of 3.10 cm x 4 cm x 0.10 cm with 1 - 24% epithelial cells and 25 - 49% of slough in the wound bed and the wound edges are attached. There was a moderate amount of serosanguineous (clear to pale yellow liquid mixed with blood) fluid from the wound. The document listed the treatment to use skin prep for the area around the wound and apply a hydrocolloid dressing weekly. No color description of the wound was provided. 5/9/24 9:38 AM - An observation of R110's wound to the right, top foot appears to be on top of the right foot at the bend where the foot meets the right leg. The wound size was approximately 2.5 cm x 5 cm x 0.1 cm and was a rectangular shape. The appearance of the wound showed approximately 75% slough tissue with 25% epithelial cells in the wound bed. There was a small amount of serous (clear to pale yellow liquid) fluid drainage. The wound edges were intact. The wound was yellow in color. 5/14/24 10:38 AM - An interview with E18 (LPN) revealed that there was an order in place to wrap R110's right foot and she is not sure if the wound on the top of the right foot came from wrapping R110's foot. Then, the order changed to not wrap the right foot. 5/15/24 1:00 PM - An interview with E40 (Wound NP) confirmed that R110's wound on the top of the right foot was a result of being wrapped too tight with kling gauze. E40 stated she asked the staff not to wrap the foot. 5/16/24 10:35 AM - In an interview with E42 (wound RN) confirmed that the treatment order dated 3/6/24, for the right heel, did not include wrapping the right heel at all. E42 stated that staff have two options to use for a clean dry dressing and they are a border gauze (rectangular pad of gauze that has sticky border around the gauze pad; larger sized band-aide) or a kling gauze (a rolled cotton gauze). E42 stated that the staff were wrapping the kling too tight and the wound was pressured related. E42 stated they spoke with E18 about it since that unit is her full-time area. E18 told E42 that she did not want the gauze to fall off. 5/20/24 1:35 PM - Findings were reviewed with E2 (DON), E4 (Consultant), and E21 (Corporate Clinical Nurse).

Based on record review, observations and interviews, it was determined that for one (R106) out of three residents reviewed for accidents, the facility failed to ensure that R106 received adequate supervision to prevent falls. R106 fell two times due to lack of adequate supervision by staff resulting in harm to the resident, broken ribs and broken nose, which required him to be transferred to the hospital for treatment and evaluation. Additionally, R106 had multiple falls due to the lack of assistance with toileting and on 8/14/23, R106 got up to the bathroom that resulted in R106's fall and broken ribs. Findings include: The facility's policy titled, Safety and Supervision of Residents dated 1/2024, documented, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility - wide priorities . Individualized, Resident - Centered Approach to Safety .4. Implementing interventions to reduce accident risks and hazards .c. Providing training . d. Ensuring that interventions are implemented; and e. Documenting interventions .5. Monitoring the effectiveness of interventions .a. Ensuring that interventions are implemented .b. Evaluating the effectiveness . Cross Refer F690 and F842 Review of R106's clinical records revealed: 6/23/23 - R106 was admitted to the facility with diagnoses including but not limited to dementia, Parkinson's disease, mood disorder muscle weakness and repeated falls. 6/23/23 - A hospital discharge summary note revealed that R106 was admitted for ambulatory dysfunction and recurrent falls likely secondary to long term alcohol use/ Parkinson's disease/postural instability, cognitive impairment with agitation and mood disorder. 6/23/23 - R106's facility Fall Risk Evaluation revealed moderate risk with a score of 13. 6/24/23 - R106 was care planned for risk for falls due to history of falls, poor safety awareness . with interventions including but not limited to ambulate as tolerated per resident's ability, assess for fall risk on admission, quarterly, bed in low position .encourage and assist as need to wear proper nonslip footwear. 6/28/23 - A facility Fall Risk Evaluation revealed R106 was a high risk to fall. 6/30/23 - R106's MDS assessments revealed that R106 was cognitively impaired with no behavioral issues. R106 required limited assistance of one staff person for bed mobility, transfer, ambulation and toilet use. R106 had a fall with no injury since his admission to the facility. 7/4/23 - A progress note by E46 (Rehab MD) documented, PT (Physical Therapy)/OT (Occupational Therapy) .Maintain fall precautions. Frequent check - ins. July 2023 - A review of R106's July 2023 facility incident reports revealed that R106 had eight falls, three of which were related to the need to toilet. 7/1/23 12:30 AM - R106 had unwitnessed fall in his room trying to use the bathroom without assistance .non skid socks not in place . 7/1/23 10:15 PM - R106 was observed sitting on his buttocks in his room .he was going to toilet .no witnesses found . 7/4/23 3:38 AM - R106 was found sitting on the floor in his room by CNA around 3:10 AM .stated, I went to use the bathroom and I fell .on my way coming out .no witnesses found . A review of the facility's Fall Risk Evaluations revealed R106 was consistently a High Fall Risk for the following dates: 7/10/23, 7/15/23, 7/22/23, 7/22/23 and 7/31/23. A follow up review of R106's fall risk care plan revealed additional interventions to include: - Ambulate as tolerated per resident's ability (revised 7/2/23) - Observe for and report development of pain, bruises, changes in mental status, ADL function, appetite, or neurological status per facility guideline post fall (7/22/23) - Review medication regimen (7/24/23) Despite having three falls associated with going to the bathroom there was no evidence that R106 was assessed for a scheduled toileting plan. August 2023 - A review of R106's August 2023 facility incident reports revealed that R106 had four falls on 8/3/23, 8/12/23, 8/14/23 and 8/18/23. 8/3/23 7:00 PM - Witnessed fall, R106 had fallen on floor in bathroom .stated, I fell on the floor trying to use the bathroom .wheelchair brakes not locked .assisted back to wheelchair with 2 person staff assistance . 8/12/23 5:00 PM - R106 was observed on the floor in his bedroom with skin tear to left elbow .stated, I fell on floor. A review of the facility's Fall Risk Evaluations revealed R106 was consistently a High Fall Risk for the following dates: 8/3/23, 8/12/23, 8/14/23, 8/17/23 and 8/18/23. A follow up review of R106's risk for fall care plan revealed additional interventions to include: - 1:1 Supervision (8/3/23) - Analyze previous falls to determine whether pattern/trend can be addressed (8/4/23) - Place appropriate call bells within reach (8/4/23) - Anti- tippers on patient's wheelchair (8/15/23) 8/14/23 9:05 AM - A late entry progress note for IDT (interdisciplinary Team) note following 8/12/23 fall documented, RCA (Root Cause Analysis): loss of balance secondary to poor safety awareness and impulsiveness further compromised by diagnosis of dementia and Parkinson (sic) Interventions .Remind resident to ask for help ambulating. 30 - minutes safety checks. 8/14/23 9:10 PM - A facility incident report submitted to the State agency documented that R106 was observed by staff sitting on the floor next to his wheelchair. R106 complained of pain to the right side of his chest. R106's X-ray results indicated broken ribs. R106 had a physician's order to be transferred to the hospital for evaluation and treatment. A written statement by E50 (CNA) documented that on 8/14/23 at 9:10 PM she saw R106 sitting on the floor in his room. 8/16/23 9:55 AM - Hospital records documented, had a ground level fall last night trying to get up to the bathroom . 8/17/23 11:00 AM - A hospital Discharge Summary documented that R106, . presented after fall and was found to have broken ribs .past medical history of .frequent falls during R106's hospitalization .was deemed unsafe to be alone, so had a one-to-one sitter ordered because he kept trying to get out of bed .This is his baseline mentation and behavior. Although R106 was care planned for 1:1 supervision to prevent falls there was no evidence that the resident was under adequate supervision when he fell resulting in broken ribs. Despite having two falls associated with going to the bathroom there was no evidence that R106 was assessed for a scheduled toileting plan. 8/18/23 2:30 AM - A facility incident report submitted to the State agency documented that R106 was observed by staff in dining room falling out of his wheelchair to the floor striking his temple area above his right eyebrow. Resident sustained laceration with hematoma over right eyebrow. R106 had a physician's order to transfer to the hospital for evaluation and treatment. A written statement by E25 (CNA) documented that on 8/18/23 at 2:30 AM, He [R106] got up the wheelchair. I told him to sit, he did and I lock (sic) the chair and I turned around to sit and he got up again and fell . 8/18/23 6:58 AM - A hospital ED (Emergency) Provider Notes revealed that R106 had bilateral nasal bone fractures. Treatment plan including laceration wound management and repair. R106 was ordered oral antibiotics for prophylaxis. A review of R106's August CNA flowsheet revealed a lack of evidence that R106 was monitored for 1:1 Supervision. Despite being care planned to 1:1 supervision to prevent falls, there was no evidence that R106 was being supervised when he fell and broke his nose. 5/20/24 1:35 PM - Findings were reviewed with E2 (DON), E4 (Consultant), and E21 (Corporate Clinical Nurse).

Based on record review, observations and interviews, it was determined that for one (R106) out of five residents reviewed for bowel and bladder, the facility failed to ensure appropriate treatment and services to restore and/or maintain bladder function were implemented. Findings include: Review of R106's clinical records revealed: Cross Refer to F641, F656, F689 and F842 The facility's policy titled, Incontinence with a revised date 1/2024, documented, Based on resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .1. must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain .4. Residents .incontinent of bowel and bladder will receive appropriate treatment .and to restore continence to the extent possible .5. Periodically (as required and when there is a change in pattern of elimination), staff will re-evaluate each individual's level of continence using quarterly and significant change re- evaluation tool. 6/23/23 - R 106 was admitted to the facility with diagnoses including but not limited to enlarged prostate and dementia. 6/23/23 - A facility new admission Bladder and Bowel Evaluation documented that R106 was continent of urine. 6/24/23 (revised 7/4/23) - R106 was care planned for risk for alteration in skin integrity related to decline in mental awareness, and decreased mobility. Interventions (initiated 6/24/23) included to check for incontinence and provide incontinent care as needed. 6/30/23 - R106's admission MDS assessment revealed that R106 was cognitively impaired, was always continent of bladder and was not on a toileting program. A review of R106's hourly voiding diary for the following: 6/24/23 - 6/30/23 five episodes of incontinence out of 238 opportunities. 7/1/23 - 7/31/23 fifteen episodes of incontinence out of 1090 opportunities. 8/1/23 - 8/31/23 twenty-five episodes of incontinence out of 500 opportunities. 9/1/23 - 9/30/23 fifty episodes of incontinence out of 803 opportunities. 10/1/23 - 10/20/23 eighty-seven episodes of incontinence out of 529 opportunities. There was no evidence of an individualized toileting program initiated for R106 despite the increase of incontinence episodes. A review of R106's CNA bladder continence flow sheet for the following: 6/23/23 - 6/30/23 two episodes of urine incontinence out of 22 opportunities (9%). July 2023 - six episodes of urine incontinence out of 89 opportunities (7%). August 2023 - fourteen episodes of urine incontinence out of 79 opportunities (18%). September 2023 - fifteen episodes of urine incontinence out of 76 opportunities (20%). October 2023 - forty-eight episodes of urine incontinence out of 85 opportunities (56%). November 2023- seventy-eight episodes of urine incontinence out of 89 opportunities (89%). December 2023 - eighty-seven episodes of urine incontinence out of 93 opportunities (93%). January 2024 - ninety-three episodes of urine incontinence out of 94 opportunities (99%). February 2024 - eighty-five episodes of urine incontinence out of 87 opportunities (98%). March 2024 - ninety-three episodes of urine incontinence out of 93 opportunities (100%). April 2024 - seventy-five episodes of urine incontinence out of 86 opportunities (87%). 7/24/23 - R106's care plan intervention for risk for falls due to history of falls was revised to include toileting schedule every 2-3 hours and as needed. 8/17/23 - A facility Admission/Readmission Screener documented that R106 was continent of bladder. 8/17/23 - A facility readmission Bladder and Bowel Evaluation documented that R106 was incontinent of urine, 8/25/23 - R106's risk for falls care plan intervention of toileting schedule every 2-3 hours and as needed was discontinued. 9/1/23 - A facility Bladder and Bowel Evaluation documented that R106 was continent of urine. 9/26/23 - R106 was care planned for physical aggression as evidenced by hitting staff related to cognitive loss with interventions including checking for unmet needs for example toilet, hunger, thirst, fatigue, pain. 9/28/23 - R106's quarterly MDS assessment revealed that R106 was cognitively impaired, was occasionally incontinent of bladder and was not on a toileting program. 11/8/23 - R106's care plan interventions for risk in alteration in hydration were updated to include [R106] will have two person assist when toileting. 12/26/23 - R106's quarterly MDS assessment revealed that R106 was cognitively impaired, was always incontinent of bladder and was not on a toileting program. Further review of R106's clinical records lacked evidence that a quarterly Bladder and Bowel evaluation was completed during the December 2023 review period. 3/26/24 - R106's quarterly MDS assessment revealed that R106 was cognitively impaired, was always incontinent of bladder and was not on a toileting program. 3/27/24 - R106 was care planned for placing self on floor/slides off chair related as evidenced by resident intentionally sliding out of chair for comfort r/t dementia. Interventions including but not limited to offer toileting. The approach did not include a frequency of toileting. 4/5/24 - A facility Bladder and Bowel Evaluation documented that R106 was incontinent of urine. 4/24/24 - A facility Admission/Readmission Screener documented that R106 was incontinent of bladder and to initiate voiding diary and develop a care plan for bladder incontinence. 5/28/24 9:01 AM - In an interview, E58 (CNA) stated, . Before [R106] broke his ribs in August 2023, he was able to stand up and wet his briefs before he reached the bathroom .or sometimes he would reach the bathroom but he was already peeing on the floor on the way to the bathroom. He needed two staff to assist him with walking. We had to get a urinal and aim it on his genitals so that if he pees while walking to the bathroom the urinal would catch and avoid spilling urine on the floor. We used to check him every two hours because he was continent when he first came, before he had those falls. Then he became an hourly check since his first fall in July 2023 . 5/28/24 9:27 AM - During an interview, E59 (CNA) stated, .I know [R106] since November 2023 and he was always incontinent with bladder. He was always wet with urine. He was not on a voiding diary but we just check on him every two hours and ask him if he wants to go to the bathroom. Sometimes he tells you if he wants to go, other times he was already wet . 5/28/24 9:51 AM - In an interview, E28 (CNA) stated, . Ever since I was assigned in this (unit), I was only able to do 1:1 sitter for [R106]. We would take him to the bathroom every two hours to check if he is wet. Or when ever I see him starting to move a lot and getting anxious, it's a signal for me to know that he may need to pee or has a bowel movement . 5/28/24 10:05 AM - During an interview, E60 (CNA) stated, .When I first had [R106] on my assignment in September 2023, he was both continent and incontinent. Sometimes he was able to tell you that he wanted to use the bathroom and found him dry but will eventually go. Other times, he's already wet when he asks us to take him to the bathroom. We toilet him every two hours .He was not on hourly toileting. 5/28/24 10:37 AM - In an interview, E39 (LPN) stated that she was not R106's primary nurse but she knew that R106 was continent of bladder and used the toilet in June 2023. E39 further stated that R106 progressively needed more help with his toilet and bathroom use probably after his fracture (broken ribs). When asked for the process when a resident has a change in bladder functional status from always continent to occasionally, frequently and always incontinent, E39 explained that it is an expectation for the floor nurse or charge nurse to assess and evaluate the resident's current bladder status to verify the change that the CNAs reported. E39 continued to state that once assessment was done, interventions will be put into place for example initiating a 3 - Day voiding diary establish a personalized pattern for when a resident would be found wet in his briefs and becomes incontinent and then come up with a toileting program to check the resident based on the voiding patterns. 5/28/24 11:02 AM - During an interview, E35 (LPN) stated that she was the UM (Unit Manager) in the (unit) last year 2023. E35 further stated, [R106] was continent/incontinent of bladder on admission - but mostly continent and was toileted every two hours unless he asked to be brought to the bathroom. He was for the most part to totally continent of bladder. Even if the CNAs were telling me [R106] became incontinent, I did not push for a change in his continent status because he was not wet, and he was always dry with me. He was continent before he fell and broke his ribs. I used to take him to the bathroom every morning and I would find him dry but he was able to go (urinate) and I would give him enough time to finish for at least 5 minutes, and not to rush him so he could completely empty his bladder. 5/28/24 11:54 AM - In an interview, E19 (RN UM/Sup) stated that since she started working in the facility, she has always known R106 to be incontinent of bladder. R19 stated that she was the temporary UM for (unit) in March 2024 and that she completed R106's quarterly bladder and bowel evaluation for the review period 4/5/24. E19 confirmed that R106's December 2023 quarterly bladder and bowel evaluation was not completed. 5/28/24 12:04 PM - During an interview, E21 (Corporate Clinical Nurse) stated that R106 showed a mix bladder continence/incontinence episodes. E21 further explained that there was no no need for a check and change or toileting program on R106 as he was showing different patterns each time. E21 stated that a staff was assigned to do 1:1 supervision on R106 and that the same staff was to take R106 to the bathroom along with another staff as R106 required a sit - to stand - up lift for toilet. 5/28/24 12:15 PM - In a follow up interview, E21 confirmed that R106's December 2024 Bladder and Bowel quarterly evaluation was not completed. Despite the facility's awareness of R106's mixed bladder continent and incontinent status, the facility failed to ensure that R106 received the appropriate treatment and services to restore and/or maintain bladder function were implemented when the facility failed to perform a thorough bladder assessment and establish a person centered toileting program. R106 was continent of bladder on admission on 6/23/23. The subsequent months showed R106's decline in bladder continence from frequently incontinent in August, occasionally incontinent in September, to always incontinent of bladder beginning December 2023. 5/28/24 2:00 PM - Findings were discussed with E1 (NHA), E2 (DON) and E21 (Corporate Clinical Nurse).

Based on interview and record review, it was determined that for one (R399) out of one resident reviewed for hydration, the facility failed to ensure that R399 was offered adequate fluid intake to prevent dehydration. This resulted in harm where R399 was transferred to the hospital with a diagnosis of dehydration and lithium toxicity. Findings include: Review of R399's clinical record revealed: 6/10/23 - A hospital laboratory result documented R399's lithium level as 1.2 mmol/L (normal 0.5 - 1.2 mmol/L). The BUN was 14 mg/dL (normal is 7.0 - 17.0), the creatinine level was 0.71 mg/dL (normal is 0.52 - 1.04). 6/14/23 - R399 was admitted to the facility with diagnoses including but not limited to bipolar disorder, mood disorder, major depressive disorder, diabetes mellitus and hypertension. 6/14/23 - E6 (MD) signed an order for lithium 900 mg by mouth at bedtime for schizoaffective disorder, bipolar type. 6/14/23 - E6 signed an order for lisinopril-hydrochlorothiazide 10 - 12.5 mg by mouth at bedtime for hypertension including a diuretic medication which can lead to dehydration. 6/14/23 - An occupational therapy note documented that R399 was independent to feed herself with supervision. 6/15/23 - A care plan documented that R399 had a potential or alteration in nutritional status related to the need for therapeutic diet secondary to diabetes mellitus. The goals were to remain within or achieve fluid balance and consume/tolerate greater than 50% of meals and 75 - 100 % of fluids provided. Interventions were to administer medications as ordered and honor food preferences. Observe skin, labs and hydration status as needed. Observe skin status, bowel habits and oral intake. Provide prescribed diet and monitor during and between meals for consumption. Review lab values and notify physician of abnormal values as needed. 6/20/23 - An admission MDS documented R399 as able to eat and drink herself with supervision and setup help only. R399 had no impairments for the upper extremities and an impairment on one side for the lower extremities. 6/20/23 - E53 (LPN) created an order to encourage 240 ml oral fluid every shift for two weeks signed by E6. The facility lacked evidence that the aforementioned order was started prior to 7/1/23, which is 10 days after the order was initiated. 6/22/23 - A care plan documented that R399 was at risk for adverse effects related to the use of antidepressant medication, use of antipsychotic medication. Monitor/record/report to MD PRN side effects and adverse reactions of psychoactive medications: . refusal to eat, difficulty swallowing, dry mouth . loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Observe for and report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation ability, lethargy, complaints of dizziness, tremors, etc. 6/27/23 - A lab result report for R399 documented that the BUN was high at 60 mg/dL (normal is 7.0 - 17.0), the creatinine level was high at 1.20 mg/dL (normal is 0.52 - 1.04) and the BUN to creatinine ratio level was high at 50 mg/dL (normal is 6-22). No new interventions intiated as a result of this abnormal lab work. 6/28/23 - An occupational therapy note documented that R399 was unable to use a spoon to scoop food and unable to hold a juice cup and R399 required maximum assistance in order to feed herself. 6/29/23 - A physical therapy note documented that R399 appeared increasingly lethargic each day and nursing was aware of the same. 6/30/23 - An occupational therapy note documented R399 declining, required maximum encouragement to participate in therapy and maximum assistance for feeding self. The aforementioned therapy notes reveal R399's decline in self-feeding from the baseline of being independent with supervision on 6/14/23 to a maximum assistance dependent on 6/30/23. A review of the CNA task sheet revealed that from 6/14/23 to 6/28/23, R399 was independent or needed supervision only along with no physical help from staff or setup help only for eating and drinking. From 6/29/23 to 7/3/23, R399 was documented as requiring total dependence with 1 person to physical assist for eating and drinking. There was a lack of a dietary assessment to calculate the hydration needs for R399. The standard practice for fluid intake is based on 30 mL per kilogram of weight. On 6/14/23, R399 weighed 212 pounds equal to 96.36 kilograms. R399 would need approximately 2,890 mL of fluid for the day. From 6/14/23 to 6/29/23, R399 was documented as eating 51% - 75% or 76% - 100% of the meals for breakfast, lunch and dinner. From 6/30/23 to 7/3/23, R399 was documented as eating on average as 0% - 25% of the meals. June 2023 fluid intake documented totals: 6/14 - 720 mL (milliliters), 6/15 - 720 mL, 6/16 - 600 mL, 6/17 - 840 mL, 6/18 - 960 mL, 6/19 - 720 mL, 6/20 - 480 mL, 6/21 - 720 mL, 6/22 - 720 mL, 6/23 - 1,080 mL, 6/24 - 720 mL, 6/25 - 480 mL, 6/26 - 480 mL, 6/27 - 860 mL, 6/28 - 600 mL, 6/29 - 350 mL, 6/30 - 480 mL. July 2023 fluid intake documented totals: 7/1 - 1,200 mL (milliliters), 7/2 mL - 1,120 mL, 7/3 - 240 mL. 7/3/23 11:19 AM - A physician note by E57 (Former AGNP) documented that nursing reports R399 with altered mental status since yesterday and worsening today. R399 was unable to participate in assessment due to altered mental status and was noted to have an elevated temperature of 101 and the blood pressure was 77/44. She recently completed Bactrim (antibiotic) for positive urinalysis test with no growth on the urine culture. R399 transported to the emergency room for evaluation. 7/3/23 11:38 AM - A nursing note by E56 (Former UM) documented R399 was unable to feed self, unable to hold a cup and max assistance with everything. E56 was called to R399's bedside at approximately 11:30 AM where R399 displayed a change in mental status, was difficult to arouse and responds to painful stimuli. Nurse practitioner made aware, 911 notified and patient to be evaluated at the emergency room. 7/3/23 - A discharge MDS documented R399 as requiring extensive assistance with eating and drinking. 7/3/23 12:40 PM - An emergency room note by P3 (MD) documented R399 presented to the ED (emergency room) for altered mental status. Per Pinnacle, (R399) has been gradually deteriorating for the last two days A lab result report for R399 documented that the lithium level was high at 3.7 mmol/L (normal is 0.6 - 1.2 mmol/L), the BUN was high at 80 mg/dL (normal is 7.0 - 18.0), the creatinine level was high at 2.7 mg/dL (normal is 0.6 - 1.0) and the BUN to creatinine ratio level was high at 29.6 mg/dL (normal is 6 - 22). R399's blood pressure was 85/52. 7/3/23 2:28 PM - A hospital history and physical by P5 (MD) documented R399 . is hypotensive, has lithium toxicity, acute renal failure. I discussed with the critical care team and she will be transferred to their service . she is critically ill, will be admitted to ICU and most likely will be started on dialysis. 9/1/23 3:58 PM - A discharge summary by P4 (MD) from the hospital documented R399 as having acute kidney failure due to dehydration in the setting of hypotension and lithium toxicity treated with dialysis. Hypovolemic shock in the setting of hypotension and dehydration treated with intravenous fluid boluses and levophed. 5/8/24 12:47 PM - An interview with F3 (R399's sister) revealed that R399 was not eating, she appeared glazed over and she was not physically getting better. R399's mental state was not close to where she could communicate effectively, she was slurring her words and she was lethargic. 5/15/24 10:41 AM - An interview with E55 (LPN) revealed that if a CNA documents a zero for eating a meal, then they would come tell the nurse and we will try to offer them something else to eat then document if a substitute was offered and why the resident refused. If the resident continues to be documented as a zero for eating a meal, then I would notify the provider. E55 could not remember R399 very well but stated that towards the end of her stay, R399 was not eating as much and we had to strongly encourage her to eat. E55 also stated that R399's family member told her that R399's twitching was lasting longer than normal. 5/20/24 8:58 AM - An interview with E54 (CNA) revealed that if a resident has a decline in eating and drinking, they check the difference between breakfast and lunch and tell the nurse the resident did not eat as much as they normally do. E54 did not remember R399 but reviewed the CNA documentation for June and July showing the change from independent to dependent eating. E54 stated that would be something she would have told the nurse about. 5/20/24 1:35 PM - Findings were reviewed with E2 (DON), E4 (Consultant), and E21 (Corporate Clinical Nurse).

Based on interview, record review and review of other documentation as indicated, it was determined that for one (R1) out of three residents sampled for a change in condition, the facility failed to ensure that Nursing personnel provided basic life support Cardiopulmonary Resuscitation (CPR) to a resident who was a full code (a designation that means to intercede if a patient's heart stops beating and/or the patient stops breathing). Upon finding R1 unresponsive on [DATE] at approximately 5:10 to 5:15 AM, facility nursing staff failed to provide CPR to R1 who had a physicians' order for a full Code. Facility staff did not check R1's code status. Due to facility staff failing to identify R1's code status, the facility failed to call a Code Blue and initiate CPR until 5:45 AM, resulting in an approximately 35 minute delay. R1 was pronounced dead by the paramedics at 6:01 AM. The facility's failure placed R1 in a situation with a serious adverse outcome of death. Due to the facility's corrective measures following the incident, this is being cited as an immediate jeopardy, past non-compliance with an abatement date of [DATE], which was verified by interviews and review of facility records. Findings include: The facility's policy entitled Cardiopulmonary Resuscitation (CPR), dated 2021, stated, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Policy Explanation and Compliance Guidelines: 1. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including (CPR), prior to the arrival of emergency medical services and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition). 2. CPR certified staff will be available at all times. 3. Staff will maintain current CPR certification for healthcare providers. [DATE] - R1 was admitted to the facility. [DATE] - A Physician's order was written for a full code. [DATE] 2:51 PM - A progress note documented that a care plan meeting was held. The team reviewed R1's code status and indicated the resident would remain a full code. [DATE] 5:33 AM - A progress note documented that at 5:15 AM, R1 was found unresponsive. E6 (LPN) was unable to obtain vital signs and R1 did not respond to a sternal rub. E5 (Nurse Supervisor) was notified, assessed R1 and pronounced R1 dead at 5:25 AM. [DATE] 5:50 AM - A progress note documented that at 5:20 AM, E5 was notified by E6 that R1 was unresponsive. E5 assessed the resident and determined R1 was not responding to a sternal rub and had no pulse. The apical (left chest) pulse when auscultated (listened to) no less than 3 minutes with no heart rate, no pulse rate and pupils were fixed with no reflex, dilated and no respirations. Upon reverification of CPR status was initiated, EMS was called. The timeline provided by the facility established that on [DATE] at 5:10 AM, R1 was unresponsive at 5:45 AM and 35 minutes later, CPR was initiated on a resident that was a full code. 4:45 AM to 4:50 AM - E5 (Nurse Supervisor) returned to the room and removed the nebulizer mask, the resident was breathing and oxygen was in place. 5:10 AM to 5:15 AM - E4 (CNA) notified E6 (LPN) to check on R1, E4 said She did not look right. E6 assessed R1, there was no response to a sternal rub, no pulse, or pulse ox reading. E6 went to E7 (LPN) and asked her to call E5. 5:20 AM - E5 arrived right away and conducted an assessment. Per E5, E6 was asked what had been done so far and What was she? (what was her code status). The response from E5 was that R1 had passed. 5:25 AM - Per E6 after E5 completed her assessment it was mentioned that R1 had expired. There were conflicting statements from the Nurse and the Supervisor about what was said regarding the resident passing or expiring or if the RN pronounced or not. 5:33 AM - E5 went to the nurses station and opened the resident's profile. Per the Supervisor, she stayed in the room to move equipment on the side when the nurse did not respond. 5:42 AM - E6 went out of the room after clearing [sic] to check resident's profile, but was unsuccessful logging in. About the same time, the nurse in charge (E5) yelled she is a full code. 5:45 AM - E5 went to the room to start CPR, while the Nurse in charge (E6) looked for the other Nurse (E7) and crash cart was wheeled to room. 5:48 AM - 911 was called; CPR continued. 5:59 AM - EMS arrived and took over. 6:25 AM - EMS pronounced the resident. [DATE] 8:00 AM - The facility determined the nursing staff failed to identify a code status and initiate CPR on a full code resident. The facility developed a plan to ensure the failure would not occur again. On [DATE] the facility plan included: - The facility contacted the contracted Nursing Staffing Agency and requested that E6 be placed on the facility's Do Not Send List. Also, the staffing Agency was provided the training material describing the process for an unresponsive resident. This material was an effort to alert and educate agency staff that worked in the facility of the new procedure. Furthermore, agency staff would not be able to work in the facility until the in person training at the facility was completed. The facility initiated response to R1's incident included: In-service education on the procedure for a code with all staff in the building, including current licensed nursing staff. The facility's plan was in place to ensure the remaining current licensed nursing staff were in-serviced prior to their returning to work at the facility, which was implemented. [DATE] 3:35 PM - An interview with EMS confirmed that on [DATE] at 5:49 AM, the facility notified 911 that an ambulance was needed and it was reported that a resident was weak and unresponsive. EMS arrived at 6:01 AM and confirmed cardiac arrest (death). [DATE] 3:36 PM - The facility was notified of the Immediate Jeopardy on [DATE] at 3:36 PM. A removal plan below was accepted on [DATE] at 6:05 PM and included: -Staff involved were suspended pending investigation. Licensed staff were re-educated on code status/CPR policy on [DATE]. On-going in-servicing to include part-time, PRN, and agency licensed staff upon entry to the facility. -Re-education was focused on timely identification of code status and initiation of CPR. -Staff were able to demonstrate/verbalize the code status/CPR procedure when a resident was found unresponsive to correct the identified deficient practice. [DATE] to [DATE] - Through interview and record review, the Surveyor confirmed the facility had regained compliance on [DATE]: - A root cause analysis was conducted identifying the lack of communication between staff and where the code status is found. - Nursing staff currently working in the facility received the education and training. - Competencies were signed by E8 (Staff Educator), E2 (DON) and E9 (RN). - Oncoming staff were provided the education and training prior to being allowed on their assigned units. - During interviews, it was confirmed post training, that staff were able to identify where to find residents' code status' and identify what the procedure was for a code. [DATE] 8:30 AM - During an interview, it was confirmed by E2 that the severity of the event was recognized and that the facility developed a training plan and initiated it on [DATE]. [DATE] 4:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 and E3 (CN). As a result of the facility's corrective measures in response to the incident, with an abatement date of [DATE] that was verified by interviews and review of facility documentation, this deficiency was cited as past non-compliance.

Based on record reviews, interviews, and review of other facility documentation as indicated, it was determined that the facility failed to ensure that all residents were free from physical abuse by R2 and R4. A total of five known residents (R1, R7, R9, R10, and R11) were abused by R2. R7 was physically abused by R2 on three different known occasions. On 8/17/2020, facility staff witnessed R2 hitting R7 on his right arm. On 9/5/2020, facility staff witnessed R2 hitting R7 on the chest and back. On 9/10/2020, facility staff witnessed R2 pushing R7 which resulted in R7 falling onto the floor. On 8/18/2020, facility staff witnessed R2 pushing R9 which resulted in R9 falling onto the floor and reopening a skin tear to his right forearm. On 9/15/2020, facility staff witnessed R2 slapping R10's face (then facility's report indicating smacking of R10's arm). On 9/19/2020, R1 verbalized to facility staff that R2 pulled R1 from her bed onto the floor of her room and R1 hit her head. On 10/15/2020, R11 verbalized to facility staff that R2 slapped R11's face. These failures put the residents at risk for further abuse. An immediate jeopardy (IJ) was called on 10/16/2020 at 4:40 PM and was abated on 10/16/2020 at 7:44 PM. In addition, on 2/10/2020, R4, a resident known with a history of physically abusing other residents, hit R3 on the right side of the face. Findings include: The facility's policy and procedure titled Abuse Policy and Procedure, last revised on 3/7/2018, stated, .Physical abuse - Includes, but is not limited to hitting, slapping, pinching, kicking, etc . Cross refer F580, F607 Example #1, F609, F610, F684, and F842. 1. Review of R2's clinical records and the facility's incident report documentation revealed: 8/2/2019 - R2 was admitted to the facility with [DIAGNOSES REDACTED]. 8/2/2019 - The Admission Nursing Assessment documented a history of mental illness and [MEDICAL CONDITION]. 5/8/2020 - The Quarterly MDS Assessment documented that R2 was severely cognitively impaired with a BIMS of 4 and had no mood or behaviors during the past 14 days. 6/3/2020 2:30 AM - Nurses Notes documented escalating anxiety, repeatedly approaching writer at nursing station, no known trigger. Redirection ineffective .states she does not want to be alone. Denies audio/visual hallucinations. Resident states she wants to go home, emotional support rendered .psych consult pending. Will continue to monitor. 6/6/2020 1:15 PM - Facility reported incident by E5 (Former ADON) in which R2 entered R5's room, R5 became loud and shoved R2 into the wall. No injuries were noted and the residents were separated. There was lack of evidence of addressing R2's wandering behavior, including entering into other resident's rooms. 8/7/2020 - The Annual MDS Assessment documented no change from the previous assessment. 8/17/2020 5:20 PM - A facility reported incident by E2 (DON) in which R2 hit R7 on his right arm, no injury to either resident. Close supervision was initiated for R2. Psych referrals were placed, and MD and R2's sister were notified. The facility's 5 day follow-up to the 8/17/2020 incident included a psychiatric referral was placed and R2 was placed on 15 minute checks. 8/17/2020 5:30 PM to 8/18/2020 3:30 PM - Q (every) 15 Minutes Resident Monitoring Form included handwritten comments of 1:1 . 8/18/2020 10:57 PM - A Nursing Note documented that between 3:00 PM and 6:00 PM, R2 required repeated redirection from approaching fell ow residents with hands raised in an aggressive manner and from pushing other residents in wheelchair around. At approximately 3:20 PM, E6 was informed by a CNA that a resident had been pushed by R2 and was lying on the floor. R9 found to be lying in room by bed on fall mat with head propped on right arm. R2 unable to give clear details of what had occurred while R9 and CNA relayed that R2 had pushed R9 when asked why she had hit yet another resident. Every 15 minutes check extended. R2 presenting resting in bed. Injury was documented as right elbow skin tear measuring 4 length, 1.5 width and 0.1 depth. 8/18/2020 3:15 PM - A facility reported incident documented that R2 shoved R9. The facility's 5 day follow-up to the State Agency documented that R2 shoved R9 and R9's skin tear to the right forearm reopened. Action taken by the facility included close supervision (1:1) initiated for R2, psych. referrals placed and that, acute illness was being ruled out for R2. The facility's incident report lacked evidence of a fall. The facility's intervention for every 15 minute checks failed to prevent a subsequent physical abuse by R2 against R9. 8/24/2020 (Initial date of 6/6/2020) Care plan for risk of unsettled relationships/conflicts was updated to include 15 minutes checks X (times) 24 hours (initiated 8/17/2020) and 1:1 supervision (initiated 8/18/2020). 9/5/2020 11:05 AM - A facility reported incident that R2 hit R7 in the chest and back. No injury was sustained by R7 and R2 was placed on 15 minute checks. The facility's 5 day follow-up documented the root cause as unprovoked aggressive behavior and the plan was for frequent monitoring. Review of the facility's Incident Report documented that E8 (LPN) heard R7 yelling stop leave me the hell alone and this nurse observed (R2) standing next to resident when approached and resident stated she hit me, call the police she punched me, skin assessment, V.S (vital signs) obtained, supervisor aware. (R7) stated that (R2) hit me in my chest and back, call the police she punched me. 9/5/2020 -Review of the facility's Incident Investigative documentation by E2 (DON) included that R2 will be placed on every 15 minute checks, MD to assess and psych has seen R2 and is stable. Social services and nursing to continue to support residents. In the investigative documentation, E10 (CNA) submitted a written statement that another resident (R10) reported that R2 has hit R10 as well. There was lack of evidence of 1:1 supervision resulting in the second physical abuse of R7 by R2 on 9/5/2020. In addition, it was not clear that the monitoring was decreased to every 15 minutes. Lastly, there was lack of evidence that the facility was aware of R10's allegation of abuse by R2, as documented in E10's (CNA's) statement. 9/9/2020 - Psychologist Progress Note documented active signs and symptoms .angry/hostile, paranoid, distorted reality, agitated. Interventions were behavior and stress management. 9/10/2020 7:08 PM - A Nursing Note documented per CNA, R2 was seen standing over R7. R7 was sitting on the floor with her hand raised in a position indicating she was about to strike him or just had. R7 stated, What was that for? (E6) separated resident then assisted (R7) to standing position then to be seated in wheelchair with no apparent injury. Skin assessment of (R7) revealed no apparent injury, Left message with Geriatric Consultant and (R2's) sister. (R2) placed on 1:1 monitoring. 9/10/2020 4:25 PM - A facility reported incident stated that R2 struck R7 and the residents were separated with neither of the residents sustaining any apparent injuries. There was lack of evidence that the facility accurately reported the incident of physical abuse when R2 pushed R7 and R7 fell on to the floor. 9/10/2020 - Review of the facility's Incident Investigative documentation by E2 (DON) Timeline of Event: 9/10 4:50 PM (R2) was observed standing over (R7) who was sitting on the floor. (R2) was observed with her hand raised in a position indicating that she was about to strike or just had. (R7) was noted saying What was that for? The interventions after this incident were that (R2) was placed on 1:1 supervision, MD evaluation, and psych referrals placed. Social services and nursing to continue to support residents. 9/10/2020 00:15 AM through 11:45 PM - Review of the facility's electronic medical record titled Safety Checks documented the resident was on one to one at all times was reviewed. There was lack of entry between 2:45 PM to 11:00 PM. There was lack of evidence of 1:1 supervision resulting in the third documented incident of physical abuse by R2 against R7. 9/15/2020 4:53 PM - A facility reported incident stated R2 hit R10 on the face. R10 had an envelope and R2 was trying to get it from R10's hand and when R10 did not give it to R2, R2 hit her on the face. No injuries or pain noted to either resident. Residents separated, assessed and 1:1 initiated for R2. The facility's 5 day follow-up documented the facility placed R2 on 1:1 supervision, psychiatric referrals to be placed, in addition to referrals to acute psychiatric facility placement. There was lack of evidence of 1:1 supervision resulting in another physical abuse by R2 for another resident, R10. UNDATED - A Psychiatric Nurse Practitioner Note documented, .Review of incidents involving physical aggression towards other residents .Assessment and plan was to continue current medications and to monitor and notify provider of any change in condition or ongoing aberrant or escalation in behavior, may need inpatient evaluation. 9/17/2020 - R2 had a room change and was no longer a roommate to R1. 9/18/2020 2:42 PM - A Nurses Note documented, Resident refused to go to her new room (# of room). She stayed in her old room (# of room) all shift and refused to get out. Explained to her that her room was changed but she won't move. Aid encouraged her to go to her room to be washed up but she won't bulge. Meds (medications) and meals tolerated. Care given, will continue to encourage to go to new room. 9/19/2020 3:13 PM - A Nurses Note documented, Resident continues to refuse to stay in her room. She went to her room this morning for breakfast then went back to her old room despite staff trying to redirect her several times without success. Resident stayed in her room most of the day. 9/19/2020 - Facility documentation titled Event 09/19/20 Investigation On 10/16/2020 at 2:00 PM, E1 (NHA) provided this document in response to the Surveyor's review of R1's clinical record in which R2 pulled R1 out of bed onto the floor and R1 hit her head. The date of the incident was 9/19/2020 at 2:00 PM. The documentation stated, .Conclusion: Based on the statements obtained the event was not witnessed. The first person to enter the room was (Name of CNA). She entered the room approximately 5 minutes after she last saw (R2) in the hallway. In response to calls for assistance from (R1). Upon entering the room she noticed (R2) was standing against the wall inside the doorway and (R1) was on the fall mat between the beds . The facility concluded that R2 could not have pulled R1 out of bed. The documentation contained ten facility staff statements. Three statements had no dates; the remaining seven had documented dates ranging from 9/21/2020 through 9/23/2020: - 9/21/2020 by E17 (CNA) documented she had heard R1 crying for help five to six minutes after E17 and the other two CNAs (E18 and E22) last saw R2 prior to the incident on 9/19/2020 at 2:00 PM. - 9/23/2020 by E16 (RD) documented .I was conducting my high risk follow-up with the floor staff on (R1) due to her continued nutritional decline on the morning of September 21, 2020. The floor staff informed me that (R1) was pulled out of her bed Saturday, Sept. 19th in the afternoon around 2 p.m., by another resident, (R2) and that (R1) hit her head. The staff heard Help coming from her room and found her lying face down, with her head on the ground, lying in vomit between the two bed facing A bed. (R1) then notified the staff that (R2) was the one that pulled her out of the bed and stated she hit her head . There was lack of evidence of the above incident in R2's clinical records. There was lack of evidence of 1:1 supervision resulting in R2 pulling R1 out of the bed onto the floor and R1 hitting her head. 9/25/2020 12:25 PM - R2 was transferred to a psychiatric hospital. 10/15/2020 2:30 PM - An interview with the facility's CNA Scheduler (E13) was conducted. The Surveyor asked for CNA Scheduling purposes, Do you know which unit and/or units require 1:1 supervision? E13 replied I usually do know. Surveyor asked Do you increase the CNA staffing to accommodate for the 1:1 supervision needs? E13 replied No, I staff to the State Minimum Staffing Requirements and it is up to the unit to do the assignment. 10/15/2020 4:00 PM - An interview was conducted with R1 who verbalized that since being admitted to the facility, she had one incident with a female resident in which R1 was pulled from the bed onto the floor and R1 hit her head. R1 denied any injury when she fell to the floor. R1 verbalized to the Surveyor that the female resident was no longer in the facility. 10/15/2020 6:15 PM - R2 returned to the facility from the psychiatric hospital. 10/15/2020 7:00 PM - A facility reported incident documented that R2 hit roommate R11 on her face and that R2 was immediately placed on 1:1 and room changed. 10/15/2020 7:49 PM - A Nurses Note documented, Approximately about 19:00 (7:00 PM) this nurse observed resident ambulating in hallway and wandering to rooms. Resident redirected to her room. While at resident room door putting on wander guard to her left ankle her roommate yelled out 'She slap me in my face.' This resident was immediately removed from room transfer to room (room #) and her belongings transfer as well. Supervisor were made aware. One on one supervision initiated and in progress. Sister has been made aware. MD being made aware. 10/16/2020 2:30 PM - An interview was conducted with R11 who verbalized that her previous roommate (R2) proceeded to pull on R11's gown, took her glasses and slapped her face. R11 verbalized that she was not injured. 10/16/2020 3:15 PM - An interview with E9 (LPN) revealed that while at the doorway of R2's room, in the process of placing a wanderguard to the resident's right ankle, R2's roommate, R11 verbalized that R2 slapped her on her face. E9 immediately instructed E15 (CNA), the assigned CNA (assigned to both R11 and R2) to transfer R2 to a private room immediately across from the nursing station while E9 contacted the RN Supervisor to arrange for staff to provide 1:1 supervision for R2. E9 confirmed that upon R2's return to the facility and the alleged physical abuse by R2, R2 was not on 1:1 supervision and that E9 had implemented this after the allegation of physical abuse by R11. E9 verbalized that another CNA was called into work to provide the 1:1 supervision. 10/16/2020 4:40 PM - The Surveyor conducted a meeting with E1 (NHA), E2 (DON) and E3 (QACC) to review the IJ Non Compliance. Shortly after this meeting, E3 provided the Surveyor documentation of 1:1 supervision of R2 with a start time of 6:15 PM to 11:00 PM signed off by E15 (CNA). This documentation was inconsistent with the Surveyor's interview with E9 (LPN) that the 1:1 supervision was initiated by E9 after she became aware of the physical abuse by R2 against R11. E3 stated that 1:1 supervision was completed, as documented in their electronic medical records. In regard to the 9/19/2019 incident involving R2 and R1, in which R1 was found on the floor, E3 stated that 1:1 supervision was implemented, although no staff was present in R1's room when R1 was found on the floor of her room; the last time staff saw R2 was approximately 5-6 minutes before they heard the cry for help by R1 coming from her room. E3 disagreed with the Surveyor that there was a lack of evidence that 1:1 supervision in place when R1 was found on the floor. 10/16/2020 6:45 PM - The Surveyor received a return call from E14 (CNA) who was contacted by the facility at approximately 6:00 PM on 10/15/2020 to come in early to provide 1:1 supervision for R2. E14 stated she arrived at the facility around 6:50 PM. Surveyor asked if there was another CNA who was performing 1:1 supervision and E14 (First name of the CNA) but I do not know her last name. Surveyor inquired was E15 (CNA) providing the 1:1 supervision? E14 replied No, as (E15's name) already had assignments. Surveyor asked When you have 1:1 supervision, do you have only one resident? and E14 replied, Usually, but if we are short staffed, we have to rotate every hour. Surveyor asked Where do you document that you had completed the 1:1 supervision for (R2's name) last evening? E14 replied, I do not document or at least I have never been told to document. Surveyor asked, So you did not document that you had completed 1:1 supervision on paper or in the computerized documentation system? And E14 replied No. E14 verbalized she is somewhat familiar with R2's behaviors and R2 has attempted to hit her, but was able to redirect and was successful. Despite the fact E14 (CNA) performed the 1:1 supervision from approximately 6:50 PM to 11:00 PM on 10/15/2020, the documentation provided by E3 (QACC) included documentation by a different CNA, E15 who did not perform the 1:1 supervision the evening of the 10/15/2020 incident. There was lack of evidence that the facility provided adequate supervision resulting in R2 physically assaulting R11. The facility's lack of interventions including supervision led to repeated resident to resident abuse by R2. Cross refer F607 Example # 2. 2. The following was reviewed from R4's clinical records and incident reports: 1/8/2019 - R4 was admitted to the facility with [DIAGNOSES REDACTED]. R4 had history of episodes of agitation. . 2/4/2019 - R4 was diagnosed with [REDACTED]. 2/12/2019 - A Care Plan for physical aggression as evidenced by hitting staff and peers was initiated on 2/12/2019. The interventions included to check for unmet needs such as toilet, hunger, thirst, pain, to provide emotional support and counseling as needed, to give R4 a clear concise explanation of anything that was about to occur, and if strategies are not working, leave and re-approach when it is safe to do so, offer choices to enhance sense of control; and to remove to quiet area. 4/22/2019 - A Care Plan that R4 displayed physical aggression toward other residents related to cognitive impairment and interventions included check for unmet needs (toilet, hunger, thirst); 1:1, activity, adjust room temperature, offer fluids, offer food, redirect, remove resident from environment, attempt to return to room, offer toileting, and remove from public area when behavior is disruptive/unacceptable. 9/1/2019 through 2/10/2020 - Review of Nurses Notes and the Facility's Incident Reporting/Follow-up revealed the following: 1/3/2020 9:54 AM - A facility reported incident documented that R4 struck R8 who went into R4's room. 1/3/2020 - A Care Plan for unsettled relationships/conflicts related to another resident coming into his room and R4 striking the resident. Interventions included discuss coping strategies and immediately separate residents if altercation occurs. 1/13/2020 11:10 PM - A Nurses Note documented that R4 tackled R9 in the dining room and R8 fell from the his wheelchair onto the floor. Close supervision was started immediately. 1/14/2020 - The facility's incident investigation documented that R4 was verbally paranoid and staff ongoing presence agitated R4, thus, intervention was revised to modified 1:1, every 15 minute checks and observation from a distance. There was lack of evidence that the care plan was updated to include the new monitoring intervention after the 1/13/2020 incident. 1/14/2020 through 1/15/2020 - Social Services Progress Notes documented contact and/or referrals to four psychiatric hospitals for placement. 1/25/2020 6:14 AM - A Nurses Note documented that the facility was continuing every 15 minutes checks for behaviors; no behaviors during this shift. 1/26/2020 7:12 AM - A Nurses Note documented R4 was alert verbal and continues on close monitoring. 2/10/2020 9:47 AM - A Nurses Note documented that R4 was walking in the hallway and walked up to another resident and hit her in the right side of the head. No obvious injuries and R4 stated they are always laughing at me. The incident was unprovoked and police were notified. 2/10/2020 2:15 PM - R4 was transferred to a psychiatric hospital. 2/10/2020 - A handwritten monitoring document for modified 1:1 was signed off by E26 (LPN) during the 7:00 AM -3:00 PM shift. . 10/26/2020 6:00 PM - An interview with E26 (LPN) revealed that she was the assigned nurse to R4 when the 2/10/2020 incident occurred at 2:00 PM, however, that she was not the staff assigned to R4 to perform the modified 1:1 supervision. E26 stated that she did not recall which staff was assigned for the supervision. E26 verbalized that she did not witness R4 hitting R3 in the face. Although E26's (LPN's) initials were documented on the monitoring document, the interview with E26 on 10/26/2020 revealed that she was not the assigned staff for the modified 1:1 supervision and was not a witness R4 physically abusing R3. The facility failed to provide adequate supervision resulting in R4 physically abusing R3. 10/30/2020 11:30 AM - Findings were reviewed with E1 (NHA), E3 (QACC), and E4 (RDOO).

Based on observation, clinical record review, interviews, review of the facility's polices and procedures, review of hospital records, and review of other facility documentation as indicated, it was determined that the facility failed to ensure emergency equipment was available for accidental extubation for 2 (R14 and R15) out of 2 active residents in the sample with tracheotomies (trach). The lack of available emergency equipment, in addition to the lack of competent trained staff in [MEDICAL CONDITION] care posed an immediate jeopardy (IJ) situation to residents with tracheotomies. The IJ was identified on 8/3/18 at 1:50 PM and abated on 8/4/18 at 10:00 AM. For one (R1) out of 1 [MEDICAL CONDITION] resident closed record review the facility failed to implement measures to prevent an unplanned removal of an unhealed [MEDICAL CONDITION] two days after the resident had previously pulled out the [MEDICAL CONDITION]. R1 sustained harm while experiencing shortness of breath and distress. Although R1 was not capable of verbalizing due to an intellectual disability, R1 became combative while the tube remained out and the stoma closed until the EMS arrived. Not being able to take full breaths contributed to R1's fear, anxiety, and pain. Findings include: 1a. Emergency Equipment The facility's policy and procedure, titled [MEDICAL CONDITION] Care, with the most recent revision date of 8/13 indicated a replacement [MEDICAL CONDITION] (trach) tube must be available at the bedside at all times. In addition, a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must be available at bedside at all times. 8/3/18 at approximately 1:50 PM - An observation of R15 was conducted with E13 (RN) and confirmed R15's room did not have a [MEDICAL CONDITION]. Subsequently, E2 (DON) was informed of the lack of [MEDICAL CONDITION] and E2 proceeded to central supply room, where the Shiley brand #[MEDICAL CONDITION] were located. E2 brought [MEDICAL CONDITION] and placed it at R15's bedside at 2:10 PM. 8/3/18 at approximately 2:50 PM -Interview with R14, a cognitively intact (per MDS assessment dated [DATE]) resident, who stated [MEDICAL CONDITION] inserted in 2010 and was a size 6. Surveyor observed a new Shiley brand #[MEDICAL CONDITION] in the third dresser drawer. 8/6/18 (9:15 AM) - Observation of the [MEDICAL CONDITION] a different Shiley brand #[MEDICATION NAME](extra long)[MEDICAL CONDITION] in the dresser drawer. 8/6/18 at 10:46 AM - Interview with E2 (DON) confirmed the [MEDICATION NAME] was placed at the bedside Saturday morning before talking with the surveyor. E2 confirmed [MEDICATION NAME] tube was available in the stock room. 1b. Competent trained staff The facility's policy and procedure (P & P), titled Emergency displacement [MEDICAL CONDITION], with an effective date 3/17 was reviewed. The P & P lacked evidence of signatures of the Medical Director, Administrator, Respiratory Therapist, Director of Nursing, and the RN Staff Developer. The P & P indicated that RN may attempt to [MEDICAL CONDITION], however, the P & P failed to indicate whether a completed competency was required prior to attempting an insertion. 8/3/18 at 2:50 PM - An interview with E17 (RRT) revealed that reinsertion of [MEDICAL CONDITION] should be completed by a competent RN. In addition, the competency re-evaluation was to be conducted annually, E17 related that her recollection was that the most recent annual was completed in (MONTH) (YEAR). The subsequent annual competencies of current staff was due in (MONTH) (YEAR). This was not completed, however, due to E17's planned absence. E17 related that she would forward the surveyor the evidence of the in-service record. 8/3/18 at approximately 2:55 PM - Staff observation and monitoring was initiated, to ensure R14 and [MEDICAL CONDITION] were not dislodged. 8/3/18 at 3 PM - Interview with E1 (NHA) and E4 (ROM) was conducted and they were advised that the lack of emergency equipment and lack of competent trained staff for insertion of a [MEDICAL CONDITION] was an Immediate Jeopardy citation. 8/3/18 at approximately 3:15 PM - E17 (RRT) initiated education and competency evaluation for the first two RNs, the day shift supervisor and the evening shift supervisor. At the completion of their in-service, both returned to the floor at 3:30 PM. 8/3/18 at 3:30 PM - Observation and monitoring of R14 and R15 was terminated. 8/3/18 at approximately 5:00 PM - E2 (DON) reported that, in consultation with E29, facility's Medical Director, and E17(RRT), the facility decided to revise the above P & P to include, allowing all licensed nurses, who have completed education and competency to reinsert [MEDICAL CONDITION]. Surveyor was provided a revised P & P dated 8/18, with signatures of E29, E1(NHA), E17, E2(DON), and E7 (SD) indicating the above changes. 8/4/18 at approximately 10:00 AM - The facility produced evidence that 48% of all licensed staff had been educated reinsertion, thus, IJ was abated. The facility failed to ensure that: -appropriate [MEDICAL CONDITION] were available at the bedside for residents with tracheotomies; -staff were trained and competent in providing care when dislodgement of [MEDICAL CONDITION] occurs. Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference on 8/8/18 beginning at 3:15 PM. 2. Review of R1's closed clinical record revealed: 3/13/18 - Admission to the facility with multiple [DIAGNOSES REDACTED]. 3/13/18 - Physicians' orders included: -[MEDICAL CONDITION]#6 Shiley (brand). Note: [MEDICAL CONDITION] must have the same [MEDICAL CONDITION] the next size down at bedside for emergencies. Respiratory Therapist to [MEDICAL CONDITION] monthly. - Oxygen [MEDICAL CONDITION]. When in room oxygen by concentrator (oxygen machine) on 2 L continuous to keep oxygen level in blood (pulse ox) at least 92%. When out of room oxygen (oxygen tank) use 8 L PRN if pulse ox under 92%. 3/14/18 - Care plan for respiratory impairment related to . history of chronic [MEDICAL CONDITION] . [MEDICAL CONDITION]. Interventions included: - Evaluate lung sounds and vital signs as needed, report abnormalities to physician. - Notify physician and family/responsible party of changes in respiratory condition. - Observe for and report adverse changes in respiratory rate, cough, respiratory effort and sputum color / consistency; observe for and report ineffective breathing patterns. 4/25/18 - Interagency Clinical Status Information (form sent with the resident when sent to the hospital) included, at 9:15 AM, R1's oxygen level was 97%, heart rate 102, BP 124/92. This form documented that R1 experienced shortness of breath and agitation and that the physician and guardian were notified at 9:08 AM. The time the resident left the facility by 911 ambulance was not recorded. 4/25/18 (9:59 AM) - Nursing note by E6 (RN, UM) Resident [MEDICAL CONDITION] resident sent to ER for evaluation. This RN did not include the time [MEDICAL CONDITION] discovered being out or R1's respiratory assessment including oxygenation level in the clinical record. 4/25/18 - emergency room provider notes documented R1 was cyanotic (grey / blue color from lack of oxygen) and the oxygen level was very low in the 80s when EMS arrival at the facility. After endotracheal tube (ET) placement into [MEDICAL CONDITION] opening by EMS the resident's oxygenation level rose to 100% and shortness of breath improved. R1's upper extremities were restrained and the ET tube was removed and replaced with a Shiley #6 with a cuff that was inflated (balloon to assist in [MEDICAL CONDITION] place). 4/25/18 (6:33 PM) - Progress note Resident returned to facility at approximately 4:30 PM from the ER [MEDICAL CONDITION] place with blood all over front neck area; bright red with dark brown, copious amount of sputum present with bright red blood mixed. Resident unable to state if in pain. Resident very combative and resistant to care and treatment at this time. Nursing was able to complete suctioning [MEDICAL CONDITION] with difficulty, will continue to monitor. Due to R1's intellectual impairment, it was unclear if the combativeness and resistance to care was the result of pain, fear and / or anxiety resulting from the recent EMS and ER experience. 4/26/18 - Care plan for Resistive / Noncompliant [MEDICAL CONDITION] to: disbelief in value of treatment initiated with the goal Dignity will be preserved through neat appearance and clean clothing. Interventions: allow for flexibility in ADL routine to accommodate mood, preferences and customary routine; check for unmet needs (toilet, hunger, fatigue, thirst); observe for and report side effects of medications; offer choices to enhance sense of control; psychiatry consult as ordered. The newly-added care plan problem above did not address R1's removal of [MEDICAL CONDITION], nor did it include interventions the facility would implement to prevent repeated removal of [MEDICAL CONDITION]. 4/27/18 (6:10 PM) - Nursing note by E14 (LPN), Resident [MEDICAL CONDITION] and then became very combative, unable to complete full set of vital signs at this time due to combativeness. Oxygen level 93% and heart rate 85, pain status unknown due to she is Nonverbal, Supervisor notified and present, MD on site and notified, gave new order to send out via 911 for eval / treat (evaluation / treatment), Caregiver on file called and notified, she left this facility at approximately 1810 pm (6:10 PM). The resident'[MEDICAL CONDITION] pulled out again on 4/27/18, two days after the previous time on 4/25/18. R1's distress and combativeness may have been due to shortness of breath, anxiety, fear and / or pain from the inflated cuff being pulled through the neck opening. 4/27/18 - emergency room provider notes documented R1 pulled out [MEDICAL CONDITION] and was last seen at the hospital two days ago for the same. Resident non-verbal, not answering questions with mild blood surrounding [MEDICAL CONDITION] site with no surrounding redness or signs of infection. BP low at 84/51. Chest x-ray revealed pneumonia and R1 was admitted to the hospital. 5/2/18 (10:38 PM) - Nursing note included that R1 returned from the hospital at 4:20 PM with redness [MEDICAL CONDITION] and oxygen level 95%. 8/2/18 (3:26 PM) - Interview with E14 (LPN) about [MEDICAL CONDITION] incident on 4/27/18 when the LPN documented the removal of the trach. E14 stated s/he did not see the resident remove [MEDICAL CONDITION] s/he was in another resident's room E14 indicated s/he documented the findings as relayed by others. When asked if there was an attempt to reinsert the trach, the nurse stated, I didn't try to reinsert since I am an LPN. 8/2/18 (3:30 PM) - Interview with E6 (RM, UM) to inquire if a reinsertion attempt was made. E6 stated there was [MEDICAL CONDITION] the bedside but no reinsertion attempt was made since it was a [MEDICAL CONDITION] it immediately closed. (referring to the hole in the front of the neck). 8/3/18 (approximately 3:00 PM) - Interview with E2 (DON) confirmed no root cause analysis was completed after either [MEDICAL CONDITION] (resident [MEDICAL CONDITION]) to determine strategies to prevent reoccurrence. The facility failed to identify and implement measures to prevent R1 from removing the [MEDICAL CONDITION] after the resident pulled it out on 4/25/18. R1 experienced harm as evidenced by shortness of breath, distress / anxiety related to the removal and reinsertion of the [MEDICAL CONDITION] on 4/27/18. R1 became agitated and combative, by striking out at staff. Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference on 8/8/18 beginning at 3:15 PM.

Based on record review, staff interview, and review of medical literature, it was determined that the facility failed to ensure that 1 (R4) out of 3 sampled residents was free from significant medication errors. R4 was admitted to the facility and was ordered medications to be administered and the facility failed to ensure these significant medications were administered. These medications included medications to treat primary adrenocortical insufficiency ([DIAGNOSES REDACTED]), medications to treat high blood pressure, medications to treat [MEDICAL CONDITION], and medications to treat [MEDICAL CONDITION]. This failure resulted in a change in condition, as evidenced by altered mental status of confusion at the beginning of the day shift on 4/28/18. Due to family's concern that R4 was very weak, the facility notified a medical provider at 3:45 PM and an order was obtained to transfer R4 to the hospital for emergent care. At the hospital, R4 was found to be in adrenal crisis. R4 sustained harm when he did not receive his significant medications. In addition, R4 was diagnosed and treated for [REDACTED]. Adrenal crisis can occur from any of the following: - The adrenal gland is damaged due to, for example, Addison disease or other adrenal gland disease, and surgery - The pituitary is injured and cannot release ACTH - [MEDICAL CONDITION] is not properly treated - Taking glucocorticoid medicines for a long time, and suddenly stop - Dehydration - Infection or other physical stress (https://medlineplus.gov/ency/article/ 7.htm) 1. Cross refer F684, Example #1. Cross refer F755. The following was reviewed in R4's clinical record: 4/27/18 at 7:00 PM - R4 was admitted to the facility from an acute care hospital following treatment for [REDACTED]. 4/27/18 and timed 11:23 PM - Nurses Note (NN), by E13 (RN) documented that resident was alert to person, place and time, denied pain, respiration easy and unlabored. 4/27/18 - admission orders [REDACTED] - [MEDICATION NAME] 20 mg. for treatment of [REDACTED]. - Fludrocortisone Acetate 0.1 mg. daily for treatment of [REDACTED]. - [MEDICATION NAME] 20 mg. daily for [MEDICAL CONDITION] timed 8:00 AM. - [MEDICATION NAME] 25 mg. daily for [MEDICAL CONDITION] timed 8:00 AM. - [MEDICATION NAME] 12.5 mg. twice a day for treatment of [REDACTED]. - Eliquis 2.5 mg. twice a day for treatment of [REDACTED]. - [MEDICATION NAME] 5 mg. daily for treatment of [REDACTED]. - [MEDICATION NAME] 125 mcg. daily for chronic [MEDICAL CONDITION] and timed 8:00 AM. 4/27/18 - Electronic Medication Administration Record [REDACTED]. 4/28/18 and timed 5:55 AM - NN documented R4 was alert, oriented to person, place and time, very pleasant, vital signs stable, no confusion, no complaints of pain or discomfort. 4/28/18 at 8:00 AM - MAR indicated [REDACTED] - two medications to treat primary adrenocortical insufficiency: Fludrocortisone and [MEDICATION NAME]. - two medications to treat [MEDICAL CONDITION]: Eliquis and [MEDICATION NAME]. - two medications to treat high blood pressure: [MEDICATION NAME] and [MEDICATION NAME]. - two medications to treat [MEDICAL CONDITION]: [MEDICATION NAME] and [MEDICATION NAME]. Review of the Omnicell (stock medications) content list revealed the [MEDICATION NAME], and [MEDICATION NAME] were all available on the unit. 4/28/18 and timed 1:33 PM - Nurses Note (NN), by E9 (LPN) documented R4 with confusion, verbal at times. Vital sign 130/80, P 91, T 98.8F, R 22 and 94% pulse ox on 2 liters of oxygen. Resident became short of breath at beginning of shift, pulse ox 80% and with increase work of breathing. Placed on concentrator on 2 liters, noted effective, as the pulse ox increased to 95%. Resident was incontinent of bowel and bladder. Resident with poor oral intake, staff assisting with meals and awaiting delivery of meds from pharmacy. Physician and family aware. 4/28/18 and timed 1:40 PM - a telephone order from R4's attending physician, E38 for continuous oxygen at 2 liters per minute via nasal cannula and may titrate oxygen to maintain pulse ox greater than 92%. 4/28/18 and timed 15:24 (3:24 PM) PM - NN documented that R4's family was in the facility and was concerned about the resident's status and current decline. A telephone call was placed to R4's attending physician, E38 and received an order to send R4 to the emergency room (ER) for evaluation and treatment. Ambulance arrived at 3:30-3:45 PM. Record review lacked evidence, of an RN Supervisor oversight to ensure that medications were being administered as ordered. 4/28/18 and timed 5:47 PM - NN documented that the medications for R4 arrived at the facility. This was approximately 23 hours after admission. Meanwhile, the resident experienced a change of condition and required transfer to the ER for evaluation. 4/28/18 - Review of the hospital ER records revealed, R4 arrived in the emergency room at 4:34 PM. ER note documented, that the discharge instructions from the hospital on [DATE] indicated to continue [MEDICATION NAME] for [DIAGNOSES REDACTED] and R4 did not receive his chronic medication since discharge from the hospital on [DATE]. In the ER, R4 was found obtunded with a fever of 101.9F, blood pressure stable, [MEDICAL CONDITION] with appropriate rate control. Chest x-ray with pleural effusion. Treatment included [MEDICATION NAME] 100 mg. by mouth every 8 hours. 5/17/18 - Hospital discharge summary, documented a brief hospital course, which indicated R4 had fever, extreme weakness and inability to ambulate in the ER and R4 had not been receiving his renal (sic) replacement therapy. R4 was admitted and worked up found to be in adrenal crisis and started on IV antibiotic for pneumonia and there was a question of UTI. Principal [DIAGNOSES REDACTED]. 8/1/18 at 2:30 PM - An interview with E9 (LPN) was conducted. E9 related that she was uncertain of R4's baseline, related to his orientation, thus, failed to identify the change of condition, from being alert and oriented to person, place, and time during the previous two shifts. E9 verbalized that R4 became short of breath at the beginning of the 7:00 AM - 3:00 PM shift, with noted use of chest muscles as he inhaled and exhaled. E9 related that she contacted a medical provider and obtained an order for [REDACTED]. E9 related that no new order was obtained, including a hold older from the medical provider on call. E9 verbalized that a family member of R4 was at bedside during day shift and family expressed concerns with resident's declining status. R4's attending physician was made aware and subsequently received an order to transfer R4 to the hospital. E9 was not able to recall the specifics related to the decline. When asked about checking availability of the medications in the Omnicell, E9 verbalized that (s)he did not recall but went on to say that often the medications were out of stock. E9 recalled calling the pharmacy about the missing medications, however, was not able to relate the time and the outcome of the conversation. When asked if the RN supervisor was informed of the unavailability of the medications, E9 reported that (s)he did not recall. 8/2/18 at approximately 1:34 PM - An interview with E37 (PA) revealed, that the only option for a newly admitted resident who becomes symptomatic due to lack of medication availability would be to send the resident to the hospital. E37 related that (s)he was not the medical provider on call on 4/28/18. E37 provided the surveyor the telephone number for the medical practice's on-call service, in order for the surveyor to obtain the time(s) of the call to the medical providers and the names of the medical provider. 8/2/18 at 2:43 PM - A telephone call was placed to the medical practice's on-call service to determine the medical provider who had received the reported call from E9 (LPN) on 4/28/18 during day shift. In response to this call, the surveyor received a call from a Risk Manager, who verbalized she will attempt to obtain this information and follow-up with the surveyor. There was no follow-up call during the survey. 8/6/18 at approximately 5:05 PM - An interview with E2 (DON) confirmed that the previously documented medications were not administered to R4. E2 reported, during the current survey, staff education was being conducted to educate all licensed nurses on the process to ensure acquisition of medications for all residents. The education included entering orders into the eMAR system, anticipated pharmacy delivery times, and accessing the Omnicell for available medications. Surveyor requested a written policy and procedure related to the back-up pharmacy services, however, no information was provided during the survey. The facility failed to: - Ensure that medications were on hand or obtained from the pharmacy or transferring facility prior to accepting a resident for admission. - Check stock medications after the resident's admission to determine if medications was available. - Take actions when a change of condition was noted at teh beginning of the shift until the family noted concern later that afternoon. Resulting in the resident's emergent transfer to an acute care emergency department where the resident was diagnosed with [REDACTED]. 8/8/18 at approximately 3:15 PM - Above findings were reviewed with E1 (NHA) and E2.

Based on record review, interviews, and review of other facility documentation as indicated, the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) resident reviewed (R4). In November and December of 2011, R4 had repeated unwitnessed falls during the evening and night shifts between the nursing station and the dining room. The timing and location of the falls demonstrated a clear pattern and need for supervision evident from the facility ' s documented incident reports and investigations. This information, however, was not utilized by the facility to develop and implement an individualized supervision plan for R4. Following a fall on 12/9/11 R4 was found with her head against a wall and sustained a hematoma of the head. R4 required emergency (911) transfer to the hospital for evaluation. After the fall facility staff documented the need to consult with therapy for an evaluation of R4 ' s seating and positioning. According to the incident report documentation it appeared " from the location of the hematoma that (R4) must have falled (sic) forward and out of her wheelchair and struck the wall in front of her " . Nurses note dated 12/10/11 stated resident back from ---(name of hospital)with [DIAGNOSES REDACTED]. Another nurses note dated 12/11/11 stated large ecchymotic area noted on forehead due to fall a few days ago. Ice applied. Record review revealed and staff interview confirmed, that the evaluation of R4 ' s seating and positioning by therapy never occurred. The facility failed to develop a plan to explore additional possible options and methods of supervision or monitoring to ensure R4's safety. Findings include: R4 had [DIAGNOSES REDACTED]. R4 had repeated falls in the facility and a care plan for fall risk was developed in 2010. According to this care plan, R4 remained at high risk for falls as of December, 2011. The care plan included interventions such as fall risk screening; reporting falls; observing for medication side effects; reporting side effects to the physician; providing a call light; a clutter free environment; a wheelchair; appropriate footwear; toileting assistance; alarms to the bed and wheelchair; fall mats on the floor at bedside and a perimeter mattress to the bed. These interventions, however, failed to include a plan for increasing staff supervision of R4 to address her pattern of evening / night shift falls. Seating / positioning issues in the wheelchair were unaddressed by the care plan as well. During November and December of 2011, R4 had a total of 6 documented falls (11/13/11 11 PM, 11/14/11 9 PM, 11/14/11 11:45 PM, 12/9/11 9:05 PM, 12/15/11 1:30 AM, and 12/19/11 6:15 AM. According to incident report and facility investigation documentation, all six of these falls occurred during the evening and night shifts. Three falls occurred in the resident ' s room (11/13/11 11 PM, 11/14/11 11:45 PM, and 12/15/11 1:30 AM) and three occurred in the area between the nursing station and the dining room (11/14/11 9 PM dining room, 12/9/11 9:05 PM dining room, 12/19/11 6:15 AM hallway). Fall investigation documentation by facility staff documented the need for increased supervision of R4. The following information was documented in facility investigation documents after the falls: -Unwitnessed fall on 11/13/11 11 PM: close supervision after fall needed because R4 " tries to get out of bed " . Had not used call bell to call for help although it was in reach; -Unwitnessed fall on 11/14/11 9 PM: R4 sitting opposite nurses station after fall where she ' s being monitored. Had not called for help prior to attempting to move from wheelchair to chair; -Unwitnessed fall on 11/14/11 11:45 PM: (less than 3 hours after previous fall) Prior to this fall, R4 had a change in behavior showing confusion and restlessness. According to an employee statement completed after the fall, the nurse noticed at 11 PM that R4 was confused and restless and was " driving her wheelchair to the walls of the nursing station " . When asked what was wrong, R4 told the nurse she was " dizzy " . The nurse wrote that she assisted R4 to bed. R4 was in her room at the time of this unwitnessed fall which occurred within 45 minutes of having confusion, restlessness, and dizziness identified by a nurse. No evidence of increased supervision of R4 at this time when she was known to be restless and dizzy was found. R4 fell when she tried to get out of bed. The bed alarm alerted the nurse. R4 was evaluated in the hospital and when she returned was " in a wheelchair in front of nursing station where she can be watched and monitored " ; -Unwitnessed fall on 12/9/11 9:05 PM: Prior to falling in the dining room, R4 had been at the nursing station in her wheelchair but then wheeled herself to the dining room; " continue to monitor resident evening time, toilet resident " . Nurses note dated 12/10/11 stated resident back from ---(name of hospital) with [DIAGNOSES REDACTED]. Another nurses note dated 12/11/11 stated... large ecchymotic area noted on forehead due to fall a few days ago. Ice applied... Following the fall on 12/9/11 at 9:05 PM, staff documented " therapy to evaluate seating and positioning " . No documentation of this was found in the clinical record. Interview with the facility ' s current rehabilitation director (E35) on 2/29/12 at 3:25 PM confirmed that no seating / positioning evaluation by physical therapy had been done. On 3/2/12 at 8:15 AM, E35 confirmed that no seating / positioning evaluation was performed by occupational therapy. E35 confirmed that the rehabilitation department had not received either a verbal or written request by nursing to conduct an evaluation of R4. -Unwitnessed fall on 12/15/11 1:30 AM: R4 had fallen in her room while trying to get up to go to the bathroom without first calling for help. R4 advised to call for assistance and after the fall was " placed in front of nursing station " ; -Unwitnessed fall on 12/19/11 6:15 AM: R4 found in front of wheelchair in hallway lying on floor moving side-to-side. According to the fall investigation report completed by facility staff: R4 was seated in her wheelchair prior to the fall without the wheels locked. An alarm was in place. R4 " frequently stands up from wheelchair " according to this report. When found, R4 was lying in front of the wheelchair lying on her left side rocking side-to-side. Prior to the fall R4 was observed " standing up from wheelchair a couple of times " and " does frequently move around in wheelchair, leans forward " . R4 was observed to be restless prior to this fall and was known to be disoriented and have impaired memory. After the fall R4 was " confused and did not know what happened " . The sound of the alarm alerted the staff who then found R4 on the floor. According to the statement of CNA (E50), she saw R4 " laying on the floor in front of her wheelchair with her legs underneath the chair. She (R4) was rocking back and forth trying to get up. I called the nurses " . According to the incident report, R4 had " no injury " . Two days after this fall, facial bruising of R4 ' s face was observed. According to a nursing note dated 12/21/11 timed 10:14 PM a CNA toileting R4 noticed " a bruise on her (R4 ' s) forehead unmeasurable (red in color) and two more bruises on her nose measuring 1 cm x 0.6 cm on the right side and 1 cm x 0.7 cm on the left side, purple in color. On 12/22/11 at 12:37 AM a nurse documented the redness of the R4 ' s peri-orbital region and called the physician who gave an order to send R4 to the ER for evaluation. R4 was transferred to the hospital for evaluation at 1:20 AM. A CT of R4 ' s cervical spine on 12/22/11 revealed a neck fracture " involving the odontoid process which extends from the body of the dens anteriorly to the base of C2 posteriorly. There is possible mild anterior subluxation of the lateral mass of C2. There are diffuse degenerative changes otherwise. There is no evidence for a compression fracture " . According to a CT scan of R4 ' s cervical spine on 12/9/11, R4 had no acute fracture-dislocation on that date which was less than 2 weeks earlier. After 12/9/11, R4 had 2 unwitnessed falls where she was found on the floor by staff. According to the Neurosurgeon consultation report of E47, " R4 was admitted to the hospital on [DATE] for " fall with cervical odontoid fracture " and that R4 " was found to have fallen at the nursing home and sustained a fracture of C2 with bruising on her facial area " . According to a readmission history and physical dated 12/27/11 completed by E28 (attending physician / medical director), " C2 fracture, facial ecchymosis, falls secondary to overall decline secondary to age and comorbidities. C2 fracture could have occurred at any point " . In an interview with on 2/21/12 at 4:44 PM E28 stated that the C2 fracture could have happened while R4 was in bed and if she is unaware of a fall she may write this in her progress note. When explained that there had been no C2 fracture on 12/9/11 and then a C2 fracture identified on 12/22/11 with two unwitnessed falls between these dates, E28 replied that all possibilities would need to be addressed. The facility failed to develop and implement a plan for increased supervision of R4 during evening and night hours when she had repeated unwitnessed falls. Staff documented the need for increased supervision and monitoring in post-fall investigation documentation. A routine supervision plan, however, for R4 during the evening and night shifts was not developed and implemented. R4 had six (6) unwitnessed falls between 11/13/11 and 12/19/11. Five (5) of these six (6) unwitnessed falls occurred between the hours of 9 PM and 1:30 AM (a 4 and a half hour time range) with the other fall occurring at 6:15 AM. Two (2) of the six (6) unwitnessed falls (11/14/11 9 PM and 12/9/11 9:05 PM) occurred while R4 was in the dining room unsupervised. The unwitnessed fall on 12/19/11 at 6:15 AM occurred while R4 was at the nursing station unsupervised. R4 was known by staff to be cognitively impaired with memory impairment and facility staff was also aware that R4 could not be relied upon to call for help before moving from her bed or wheelchair. Facility staff identified the need for a seating and positioning consultation by the therapy staff after R4 ' s fall on 12/9/11. This never occurred because of ineffective communication between the facility's nursing staff and rehabilitation staff. R4 fell two more times after this. R4 was found on the floor on 12/19/11 at 6:15 AM with her legs underneath her wheelchair. Two days after the 12/19/11 fall, R4 was observed with facial bruising and a C2 neck fracture was identified in the hospital. In a written response to the surveyor ' s findings, the facility wrote that the facial bruising observed on 12/21/11 was related to the hematoma obtained on 12/9/11 which was "disseminating" and that the C2 fracture "could have occurred anytime due to osteoporosis". The facility failed to ensure that an effective supervision plan was developed and implemented for increased supervision of R4 during evening and night hours when she had repeated unwitnessed falls. R4 sustained a fall on 12/9/11 and was found on the floor with her head up against the wall .Documentation in a nurses note dated 12/10/11 stated resident returned from the hospital with [DIAGNOSES REDACTED].A nurses note dated 12/11/11 stated a large ecchymotic area noted on forehead due to fall a few days ago. R4 sustained harm following the 12/9/11 fall.

Based on record review and staff interviews, it was determined that the facility failed to ensure that one (R24) out of 24 sampled residents was provided with sufficient fluid intake to maintain proper hydration and health. The facility failed to identify the increased risk of dehydration for R24 when the resident had only 300 cc (cubic centimeters) of fluids during a four day period of time. The facility failed to respond in a timely manner to the resident's inadequate fluid intake resulting in the resident being admitted to the hospital where she was found to have abnormal laboratory values and dehydration. Findings include: R24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident was moderately impaired for decision making. In addition, the resident required supervision and set up for eating. A Medicare MDS assessment dated [DATE] indicated a decline in eating to totally dependent with one person physical assist. Admission medications included [MEDICATION NAME] 10 mg BID (twice a day), [MEDICATION NAME] 25 mg BID (can cause sedation), [MEDICATION NAME] 5 mg QD (daily), [MEDICATION NAME] 0.05 mg QD, and [MEDICATION NAME] 20 mg QD. On 11/29/08 the nurse practitioner (E26) added [MEDICATION NAME] 0.25 mg every 8 hours as needed for increased anxiety and agitation (can cause sedation). On 12/7/08 the psychiatrist (E31) increased the [MEDICATION NAME] to 25 mg TID (three times a day) and the [MEDICATION NAME] to 0.25 mg TID hold for sedation. The resident was exhibiting behaviors of agitation including hitting, biting and kicking staff. The admission blood work at the facility dated 11/29/08 indicated the resident's blood urea nitrogen (BUN) level was elevated at 26.0 (normal range 8-23 mg/dL) and that the creatinine level was normal at 1.30 (normal range 0.6-1.5 mg/dL). In addition, the sodium level was within normal limits at 139 (normal range 137-145 mMOL/L). BUN, creatinine, and sodium levels are indicators of fluid imbalance and renal function. Repeat blood work on 11/30/08 indicated a BUN elevated at 32, creatinine elevated at 1.6 and a normal sodium at 138. There were no new physician orders [REDACTED]. The facility's policy Hydration Assessment and Monitoring documented that a resident who had been identified as being at risk for dehydration should be placed on Intake and Output (I&O) monitoring and documentation every shift for at least three days or until improved. The policy indicated that this should be placed on the care plan. Additionally, the policy documented that at the end of each 24 hour period the resident's fluid intake should be compared to the minimal fluid requirement of 1500 cc/day. It further revealed that a nurse may initiate I&O at any time based on professional assessment and judgement. On 11/28/08 staff initiated a three day intake and output record that according to Standing Physicians Orders signed 11/29/08 which was done on all new admissions. Facility staff failed to make entries each shift and failed to total what they did enter. There was no evidence that this document was evaluated by staff to identify a hydration risk. A hydration risk assessment completed on 11/28/08 by nursing staff scored 10 which indicated the resident was not a high risk for dehydration. However, the staff completing the form did not have sufficient information to complete all areas of assessment. Had the first three days of resident intake been evaluated the resident would have coded high risk for hydration. The review of the initial nutritional assessment by the registered dietitian (E29) dated 12/1/08 documented that R24 was at nutritional risk secondary to leaving greater than 25% of meals uneaten and her estimated fluid requirement was 1650 cc. The speech therapist (E30) assessed the resident on 12/5/08 and indicated the resident was at risk for inadequate nutrition and hydration. The facility had an interim plan of care that identified hydration as a problem area on 11/30/08 with the approaches to provide fluid as ordered and monitor labs. Hydration needs were not included in the full care plan developed by the interdisciplinary team. The facility did document a hydration risk stamp nurse's note on 12/4, 12/10 and 12/19/08 that failed to identify the lack of sufficient fluid intake by R24. The stamp on 12/19 did identify amber colored urine. On 12/9/08 the resident was started on an antibiotic for treatment of [REDACTED]. The facility's General Hydration Policy and Procedure documented "8. Report refusals of fluids or problems ingesting fluids to the charge nurse, so she can report it to the physician". The document "Fluids" record kept by direct care staff to document the cc's of fluid consumed at meals, snacks and extra was reviewed. This form collects data but has no area to total the daily fluids to evaluate the residents intake. Calculations by the surveyor indicated that for the 23 full days that R24 was at the facility she consumed an average of 446 cc per day. Ranging from 960 cc to 0 cc each day. The last four full days (12/18 thru 12/21/08) the resident was at the facility a total of 300 cc's were consumed. The resident took no medications by mouth 12/20, 12/21, and 12/22/08 due to sleeping and lethargy. The resident's blood pressure (BP) also decreased from an admission BP of 140/62 to the last three days of admission 12/20 -118/74, 12/21 - 110/64, 12/22 -90/48 and 88/50 which can also be indicative of [MEDICAL CONDITION] related to volume depletion. On 12/19/08 the nurse practitioner (E26) ordered an extra 240 cc of fluid each shift for hydration and to document the amount consumed. Staff were able to get R24 to consume 55 cc on 12/19/08 and no additional fluids after that date. There was not evidence that this lack of consumption was reported to E26. Interviews on 4/23/09 with the DON (E19) who reviewed the 24 hour report and physician communication book, the nurse (E27) who cared for the resident daily and E26 who visited on 12/19/08, revealed that there was no contact with the physician concerning the lack of intake and increased lethargy until 12/22/08 at 1:30 PM when R24 was sent out 911 to the emergency room . These findings were confirmed on 4/23 and 4/28/09 with the Administrator (E18) and DON (E19). R24 was admitted to the hospital with [REDACTED]. The resident had an elevated BUN at 172, elevated creatinine of 7.1 and an elevated sodium at 175.